EZ-NET User Request
Requesting Provider's Information
Provider's Full Name:
Users (Full Name/Job Title):
ProvID:
TaxID:
Phone:
Enter a valid phone number, preferrably like 000-000-0000 x00000
Email:
Enter a valid email address
Access Requested
I'm requesting access for others too:
First Name:
Last Name:
Phone:
Email:
Access:
Auth Inquiry (ai)
Claim Inquiries (ci)
Eligibility Inquiries (ei)
Auth Submission (as)
Groups:
HVMG
CMG
First
Last
Phone
Email
Access
Groups
Delete