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Online Bill-Pay Access Request Form for Brokers
Please complete all fields and click 'Submit'. Fields marked with an * are required.
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Group Information
Group & Sub Group Numbers You will Access: *
(Please include subgroup numbers with no dashes or spaces)


   (5-8 numbers or letters, no symbols)
1st Choice: 2nd Choice:
Broker Information
  First Name Last Name
   (up to 40 characters in length)
Group/Organization's Authorization: *  

I understand that the broker 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. I consent to the following additional Plan Sponsor’s Designation of Appointed Broker - Terms of Access/User (PDF).

  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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