iExchange® Enrollment Form

This form is intended for use by contracted providers (physicians, physician groups, professional providers and facility providers).

* All fields are required.

* Provider / Office / Group Name:

* Tax ID:

*Billing National Provider Identifier (NPI):

* Primary Specialty:

* Assigned Administrator’s First and Last Name:

* Address (Location where services are rendered):

* City / State / ZIP Code:


* Assigned Administrator’s Phone Number:

* Assigned Administrator's Email Address:

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

Updated May 2018

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. Blue Cross and Blue Shield of Illinois makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.