Nurse Registration

Note: Fields marked with a red * are required.

Applicant Information

Which type of CSN Provider are you?
If you work as an Independent Nurse and an Agency Nurse you can register as either one. You will be allowed to enter in a profile for both.

Agency Nurse

Independent Nurse

Agency

Confirmation

Please make sure you made right selection for type of CSN provider (Agency/Independent) type."

First Name

Last Name

Street Address

City

State

Zip Code

Home Phone Number

Cell Phone Number

MassHealth Provider ID and Location

State License Number

Is your CORI up-to-date and in good standing?

Yes	No

Is your license active and in good standing with the State Board of Nursing?

Yes	No

Preferred initial contact method:
To receive text messages, select the "Text Messages" option and make sure to provide a valid cell phone number.

E-mail

Phone

Cell phone

Text message

Password

Confirm password

Password must be at least 8 characters long.
Passwords must have at least one non letter or digit character (!,#,$,%,^,?,*,_,-).
Passwords must have at least one digit ('0'-'9').
Passwords must have at least one uppercase ('A'-'Z').
Passwords must have at least one lowercase ('a'-'z').

Make a selection

Please select a city from the list bellow

City Selection

ForHealth Consulting at UMass Chan Medical School
The public service consulting and operations division of UMass Chan Medical School
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