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:
* Contact Phone Number:
* Is your office a current iEXCHANGE Web user for another health plan?
Note: The iEXCHANGE Help Desk will email your iEXCHANGE ID, User ID and temporary password. Please allow seven business days for processing.