(Fields marked * are mandatory)
User Details
First Name * Last Name *
Gender * Date Of Birth *
(mm-dd-yyyy)
Street Address * Zip Code *
State * City *
Phone * -- Cell Phone * --
Receipt Number/ Member Id * Insurance Company  
( OPTIONAL )
Email *
(This will be your user ID)		 Email
Confirmation *
Your Password must contain:
At least 2 special characters (!@#$%^&*)
At least 2 capital letters
At least 2 numbers
At least 7 digits long
Password * Password
Confirmation *
Security Questions
Question #1 What city were you born in?
Answer #1 *
Question #2 What is your favorite color?
Answer #2 *
Question #3 What was the name of your favorite pet?
Answer #3 *
Question #4 What is the make and model of your first car?
Answer #4 *
Question #5 What is your favorite food?
Answer #5 *
   I certify that I have read and understand the following:
              Terms of use statement
              My rights under the Health Insurance Portability and Accountability Act (HIPAA)
              InstaHEAL's privacy policy
 
           For added security, please type the characters in the image below exactly as they appear.
                                                                             
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