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iEXCHANGE® Web Enrollment Form

Note: Provider includes Physician, Professional Provider and Facility Provider

(*) Indicates a required field.


* Office Administrator's First Name:

* Office Administrator's Last Name:

* Office Administrator's Email Address:

* Provider / Office / Group Name:

* Primary Specialty:

* National Provider Identifier (NPI) Number:

* Tax ID:

* Address (Location where services rendered):

* City / State / Zip Code:

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* Contact Phone Number:

* Is Your Office a Current iEXCHANGE Web User for Another Health Plan?

 Yes     No
 
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Note: The iEXCHANGE Help Desk will email your iEXCHANGE ID, User ID and temporary password. Please allow seven business days for processing.


Updated 04/2013