iEXCHANGE® Web Enrollment Form

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

* All fields are required.


* Provider / Office / Group Name:

* Tax ID:

* NPI Number:

* Primary Specialty:

* Assigned Administrator’s First and Last Name:

* Address (Location where services were rendered):

* City / State / Zip Code:

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* Contact 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 April 2018