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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.
Type of Facility
User ID 1st Choice
User ID 2nd Choice
Facility or Business Name
Federal Tax Identification Number
Street Address 1
Street Address 2
Authorized Requestor's Name
Authorized Requestor's Phone Number
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.
GDPR Notification Content