Online Enroll & Access Request Form for Employer/Group Administrators

Please complete all fields and click "Submit".
We protect the privacy of your message with SSL encryption (opens a tooltip).

Company Information

Company Information*

(Include subgroup numbers with no dashes or spaces.)

Existing Employer Web Account*

5-8 numbers or letters, no symbols, special characters, or spaces.

Request Information

Company's Authorization:

Please review then continue

  • 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.
  • The access is necessary in order to perform certain administrative functions.

Name of Person Granting Authorization:

e.g. Human Resources Manager or Payroll Manager.

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