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Please complete the following form.

Health Care Provider /Office Name*:
Address*:
City*:
State/Province*:
Zip*:
Tax ID*:
National Provider ID*:
Office Specialty*:

Are you currently submitting transactions via iEXCHANGE?
Yes
No
Do you use Availity? Yes
Do you use NaviNet? Yes

System Administrator Contact Information

Delegated administrative user who will have the ability to create and maintain user IDs for the provider group.

Salutation:
First Name*:
Last Name*:
Title:
Phone*:
Email*:

Select the health plans in your area for which you would like access and please provide your health plan provider ID number(s)*:

AmeriHealth Administrators
Independence Administrators
AmeriHealth Mercy Health Plan
KePRO (Florida)
Blue Care Network
Delmarva Foundation for
Medical Care, Inc.
Blue Cross Blue Shield of Delaware
Blue Cross Blue Shield of Illinois
Keystone Mercy Health Plan
Blue Cross Blue Shield of
New Mexico
Lovelace Health Plan
Blue Cross Blue Shield of Texas
Passport Health Plan
CareFirst
Qualis Health
WPS Health Insurance
Arkansas Foundation for
Medical Care
Blue Cross Blue Shield
of Oklahoma

Are you a Facility?

Yes

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For more information or to request a demonstration on our products and services, please contact us or call us at 610-540-0202.

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