EZ-NET User Request
Requesting Provider's Information
Provider's Full Name:
Users (Full Name/Job Title):
ProvID:
TaxID:
Phone:
Email:
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:
MD Senior Care
First
Last
Phone
Email
Access
Groups
Delete