iEXCHANGE® Web Enrollment Form

Note: Provider includes Physician, Physician Group, Professional Provider and Facility Provider.

* All fields are required.


* 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 were 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

Note: The iEXCHANGE Help Desk will email your iEXCHANGE ID, User ID and temporary password. Please allow seven business days for processing.