Medical Group Registration

To initiate activation of your account, please fill in the following fields, then click the "SUBMIT" button. Upon receipt, a Radiant Behavioral representative will contact you to complete the activation process.

If any questions, please call: 1-800-717-0955

Practice/Facility Name:
Number of facilities/locations:
Main facility street address* :	Suite#:
City* :	State* : Zip/Postal Code* :

Add Another Facility/Location
Main Contact:
First* :
Last* :
Position/Title :
Office Phone*	Ext: Cell:
Email Address* :

Add Another Contact
Website:

Select a Payment Plan

See what's included

Monthly Payment Plan ………………………………………………………………………… $295/mo
(One time set-up fee $150)

Annual Payment Plan (Save 25%; Equal to $220/mo)…………………………………… $2,650/yr
(One time set-up fee WAIVED!)

First month fee:

One time set-up fee:

$150

Total:

$150

Subsequent month fee:

Total:

Promo Code (Enter code, then click the "Apply" button)

Enter Promo Code:

(NOTE: If you do not have a Promo Code, leave blank)

Billing Options

Please specify how you wish to pay for the service

By credit/debit card

By check

Accounts Payable Contact:
First* :
Last* :
Office Phone*	Ext:
Billing Address* :	Same as main office address
Street Address* :	Suite#:
City* :	State* : Zip/Postal Code* :
Email Address* :
Retype Email Address* :

Customize Your Domain Name

Enter your name, some variation of your name, or the name of your practice to create your own custom website address (this is the website address you and your patients will log into). The name you enter will precede the parent domain name which is “LIFESPANPLATFORM.COM”. For example, if you enter “DrSmith” then your website address will be: “DrSmith.LIFESPANPLATFORM.COM”.

Other examples:

SusanSmithMD.LIFESPANPLATFORM.COM
DrSusan.LIFESPANPLATFORM.COM
SmithMedical.LIFESPANPLATFORM.COM

Enter the desired name below and then click the “Check Availability” button. NOTE: Enter only the desired name that will precede the parent domain. DO NOT type in “www” or the parent domain “LIFESPANPLATFORM.COM”. Also, do not input any spaces or special characters, only alpha or numeric.

You may input up to 20 characters.

Feel free to use all upper or lower case or any combination of upper and lower. Domain names are not case sensitive, so your clients will be able to access your website using any case they choose to type in.

e.g. DrSmith (Do not enter “www” or “LIFESPANPLATFORM.COM”)

I hereby affirm that I have reviewed and approve of the Terms of Use and Privacy Policy of the Behavioral Health Checkup platform.