hospital_facility_registration

Hospitals, Group Practices, and Facilities Web Registration

An administrator of your hospital, group practice, or facility must complete and return this form. We will then create a "master account" where an administrator will be responsible for managing staff access.

An administrator of your hospital, group practice, or facility must complete and return this form. We will then create a "master account" where an administrator will be responsible for managing staff access.

*Required Field

*Required Field

Type of Facility

Type of Facility null

Request Type

Request Type null

User ID 1st Choice

User ID 1st Choice 5-20 characters, no symbols, special characters, or spaces null

User ID 2nd Choice

User ID 2nd Choice 5-20 characters, no symbols, special characters, or spaces null

Your Name

Your Name First and Last Name null

Phone Number

Phone Number ###-###-#### null

Email Address

Email Address null

Facility or Business Name

Facility or Business Name e.g. Rochester Group null

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number null

NPI

NPI 10 digit National Provider Identifier null

Street Address 1

Street Address 1 Street Address/P.O. Box null

Street Address 2

Street Address 2 Apartment/Suite/Unit/Building/Floor

City

City null

State

State null

Zip Code

Zip Code 5 digit zip code null

Authorized Requestor's Name

Authorized Requestor's Name First and Last Name null

Authorized Requestor's Phone Number

Authorized Requestor's Phone Number ###-###-####

Authorized Requestor's Email Address

Authorized Requestor's Email Address

Excellus BlueCross BlueShield is committed to protecting the privacy of our members. By requesting access to our online service center, you agree that:

• You and your employees will use this information only in the delivery of patient care and will keep such information confidential, in accordance with law.

•Information concerning any member, employee, group and/or patient will not be released to any third party not entitled to such information nor made accessible to persons having no legitimate reason to know such information.

•You and your employees will keep the User IDs and Passwords in a secure location to prevent unauthorized access.

•If an employee leaves your organization, you will log in and delete the employee's account so that he or she no longer has access.

•Any breach of confidentiality by you or any of your employees will be grounds for immediate revocation of access to this system.

Excellus BlueCross BlueShield is committed to protecting the privacy of our members. By requesting access to our online service center, you agree that:

• You and your employees will use this information only in the delivery of patient care and will keep such information confidential, in accordance with law.

•Information concerning any member, employee, group and/or patient will not be released to any third party not entitled to such information nor made accessible to persons having no legitimate reason to know such information.

•You and your employees will keep the User IDs and Passwords in a secure location to prevent unauthorized access.

•If an employee leaves your organization, you will log in and delete the employee's account so that he or she no longer has access.

•Any breach of confidentiality by you or any of your employees will be grounds for immediate revocation of access to this system.

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