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Office Information

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

iEXCHANGE ID

NO
Do you use Availity?

YES NO
Do you use NaviNet?

YES NO
Are you a Facility?

YES NO

Please provide the names of physicians affiliated with your practice that will require access to iEXCHANGE:

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

First Name*

Last Name*

Phone*

Email*

DaVita Medical Group

Blue Cross Blue Shield of New Mexico

Independence Administrators

AmeriHealth Administrators

Blue Cross Blue Shield of Oklahoma

WPS Health Insurance

Blue Cross Blue Shield of Texas

SmartHealth

Blue Cross Blue Shield of Illinois

WYhealth

SutterSelect

Please fill in the fields that are marked with an *.