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Online Bill-Pay Access Request Form for Employer/Group Administrators
Please complete all fields and click 'Submit'. Fields marked with an * are required.
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Group & Sub Group Numbers You will Access: *


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

I understand that the group representative named above will have access to bank account information (for electronic funds transfer) and 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.

  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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