To access ProviderCONNECT, in-network contracted providers must identify one individual who will serve as their Local Administrator and will be responsible for managing all other users who access Partners’ ProviderCONNECT for that provider organization.
To maintain the integrity of the provider portal and ensure only appropriate individuals have access to provider information inside the portal, this form must be signed by the CEO of the agency/practice associated with the tax id number indicated on this form.
 
Designated portal administrators must complete the form below, include your Chief Executive Officer’s/authorized contract signature, and submit. 

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* 1. Date of Request

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* 2. Practice/Agency Tax ID Number:

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* 3. Name of the Person to be designated Portal Administrator for this Agency/Practice:

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* 4. Email address for the Local Administrator:  

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* 5. Phone Number for Local Administrator:

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* 6. Authorized Signatory Name:

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