MHMAS:

Registration

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Organizations

Organizations represent official groups that you have affiliation with as a MHMAS user. Click the Add Organizations link below to see a complete list of organizations and select those you want to join.

Add Organizations

Organization(s):

Account Information

Creating an account is the first step in the MHMAS - Montana Healthcare Mutual Aid System registration process. You will use your account username and password each time you log into MHMAS - Montana Healthcare Mutual Aid System.

Username:

The username must be at least six (6) characters long and cannot contain spaces. Acceptable characters include alphanumeric (A-Z, 0-9) and the symbols @, ., -, and _. Usernames are not case sensitive.

Password:

Confirm Password:

Secret Question:

Secret Answer:

Terms of Service and Privacy Policy

Required field Terms of Service:

By checking this box, I indicate that I agree to the Terms of Service and have read and understand the Privacy Policy for this site. My submission of this form will constitute my consent to the collection and use of this information and the transfer of this information across the Internet to processing and storage facilities supporting this system. I also agree to receive required administrative and legal notices such as this electronically.

Required field Information Pledge:

By checking this box, I pledge to provide only correct information when completing this registration process. I also give consent to MHMAS - Montana Healthcare Mutual Aid System and their designated agents to collect, use, verify, and maintain any information that is collected through the use of this site.

Name and Address

Prefix:

Example: Dr., Col., Mr., Mrs., Ms.

First Name:

Middle Name:

Last Name:

Suffix:

Example: Jr., Sr., MD., PhD, RN

Home Address Line 1:

Home Address Line 2:

City:

State:

Required field County or Tribe of Residence:

County Tribe

If you are a tribal member, a tribal designee, or currently employed by a tribal government, please enter a Tribe of Residence.

County:

Zip Code:

Work State:

Alternate Address Line 1:

Alternate Address Line 2:

City:

State:

Zip Code:

Identifying Information

Date of Birth:

Social Security Number:

SSN is used to verify certain licensure information and for identification purposes.

Gender:

Contact Information

Primary Email Address

Delete

Email Address:

If you have an email account, it is important for you to provide this information. Without your email address, you may miss important messages and notifications. Please note that the system will not allow two accounts with the same email address. If you do not have an email address or your email address is already registered with the system, you can learn more about obtaining a free email address by clicking here.

Confirm Email Address:

Add Email Address

Contact Method 1

Delete

Contact Method 1:

Number to Attempt:

Pager Type:

Pager Carrier:

Pager ID/PIN:

Phone Carrier:

Add Another Contact Method

Primary Emergency Contact

The individual to contact in the event of a personal emergency during deployment.

Emergency Contact Name:

Relationship:

Primary Contact Number:

Secondary Contact Number:

Secondary Emergency Contact

The individual to contact in the event your primary contact is unavailable.

Emergency Contact Name:

Relationship:

Primary Contact Number:

Secondary Contact Number:

Tertiary Emergency Contact

The individual to contact in the event your primary and secondary contacts are unavailable.

Emergency Contact Name:

Relationship:

Primary Contact Number:

Secondary Contact Number:

Occupation Information

What is your occupation type?

Occupation:

If your occupation does not appear in the list, please select Other.

What is your current professional status for this occupation?