bkr_enroll_update_access_request

Online Enroll & Access Request Form for Broker

*Required Field

*Required Field

Group Information


 

Group Information


 

Group/Organization Name

Group/Organization Name null

Group & Sub Group Numbers You will Access

Group & Sub Group Numbers You will Access group and sub group - 12 digit number (click + icon for additional entries) null

Do you already have a web account for this group?

Do you already have a web account for this group? null

Username

Username 5-8 numbers or letters, no symbols

1st Choice for Username

1st Choice for Username 5-8 numbers or letters, no symbols

2nd Choice for Username

2nd Choice for Username 5-8 numbers or letters, no symbols

Enroll/Update Access

Enroll/Update Access null

Broker Information


Please Note:  Broker name and email address must correspond to the same person.

Broker Information


Please Note:  Broker name and email address must correspond to the same person.

Broker Name

Broker Name First and Last Name null

Email Address

Email Address null

Phone Number

Phone Number ###-###-#### null

Agency Name

Agency Name null

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number null

Group / Organization's Authorization

 

  • The group administrator named below understands that the broker named above will have access to protected health information of members enrolled in their group/organization's health insurance programs, made available through the Health Plan's online service center.
  • The access is necessary in order to perform certain administrative functions.
  • The group administrator named below has consented to the following additional Plan Sponsor’s Designation of Appointed Broker - Terms of Access/User (PDF)
Group / Organization's Authorization

 

  • The group administrator named below understands that the broker named above will have access to protected health information of members enrolled in their group/organization's health insurance programs, made available through the Health Plan's online service center.
  • The access is necessary in order to perform certain administrative functions.
  • The group administrator named below has consented to the following additional Plan Sponsor’s Designation of Appointed Broker - Terms of Access/User (PDF)

Authorization Agreement

Authorization Agreement null

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager)

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager) First and Last Name null

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

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

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