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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*

AmeriHealth Administrators

Independence Administrators

LA Care

Piedmont Community Health Plan

WPS Health Insurance

WV PEIA

WYhealth

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