iEXCHANGE® Web User Set-Up Questionnaire

Note: Provider includes Physician, Professional Provider and Facility Provider

(*) Indicates a required field.


* National Provider Identifier (NPI) Number:

* Tax ID:

* Provider Name:

* Primary Specialty:

* Provider Address:

* Provider City:

* Provider State:

* Provider Zip Code:

* Provider Office Phone Number:

* Patient Clinical Summary (PCS):

Yes
No

* Assigned Administrator First Name:

* Assigned Administrator Last Name:

* Assigned Administrator Phone Number:

* Assigned Administrator E-mail:

* Is Your Office a Current iEXCHANGE Web User for Another Health Plan?

Yes
No
  

Note: The iEXCHANGE Support Desk will email your Account Administrator your iEXCHANGE ID, User ID and temporary password. Please allow five (5) business days for processing.

 

Updated 01/2011