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New SCI PAS Account Creation

If provider has accessed SCI PAS previously, please click on HOME to return to log in page.
For assistance, please contact the Help Desk at 866-439-4082 (select option 2, Immunization Registry).


All fields in bold must be completed to submit for SCI PAS account creation.

Facility Name :
(as it appears on W-9)
Practice Name (or Doing Business As):
(If Different from Facility Name above)
 
Name of Electronic Signature Authority (ESA):
(first)

(middle)

(last)
Position / Title of ESA:
Federal Employee Identification Number (FEI): Organization's NPI:
Facility Address (no P.O Box):
City: State: Zip:
County:
Facility Phone Number:
Facility Phone Number Ext:
Email Address
(this will be your user name)
Password:
(enter password)

(re-enter password)
Enrollment/Registration Type(s):