User Registration - MIDAP.Web

Instructions

All boxes with a red asterisk (*) need to be filled to register.
Please select Submit button after you are done.
Before you start the application MDHHS needs to know if you are filing the application out on your own or are getting help from another person. If you select an option that needs to be changed or was not correct MIDAP/MDP can make a change for you. Choose from below:
- If you are applying for MIDAP/MDP services, select Client.
- If you are a Case Manager, select this type.

Registration

Contact Information

* First Name

Middle Name

* Last Name

* Phone Number

Phone Number Extension

* Email

Address

Mailing Address

Apartment Number

City

State

County

Zip Code

Roles

* User Role Selection

Client

* User Role Selection

Case Manager

Agency

Personal Information

Social Security Number

Date of Birth

Maiden Name

Preferred Name

Have you ever been on MIDAP?

Yes

MIDAP ID XXXXXXXX

Have you ever been on MDP?

Yes

MDP ID

Notice of Privacy and Security

MDHHS will ensure the protection of your health information and maintain compliance with applicable federal and state confidentiality laws.

I agree that the information I have provided is true and complete to the best of my knowledge. I certify that I meet the eligibility requirements as specified in the MIDAP Instructions.

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