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Annual Group Information Form - Access Request for Employers
Please complete all fields and click 'Submit'. Fields marked with an * are required.
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Group & Sub Group Numbers You will Access: *





5-8 numbers or letters, no symbols
 
  First Name Last Name
  ###-###-####
 
Company's Authorization: *  

I understand that the group representative named above will have access to protected health information of members enrolled in my organization’s health insurance programs, made available through the Health Plan’s online service center. This access is necessary in order to perform certain administrative functions.
 


  First Name Last Name

 
Please allow five business days for us to process your request. We will notify you by email once your web account is ready.
 
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