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Annual Group Information Form - Access Request 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
 
Broker Information
  First Name Last Name
  ###-###-####
 
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. This 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).
 


  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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