individual_practice_registration

Individual Practice Registration

An administrator of your practice must complete and return this form. We will then create a "master account" where an administrator will be responsible for managing staff access. Only authorized staff at your practice have access to health plan information for your patients.

An administrator of your practice must complete and return this form. We will then create a "master account" where an administrator will be responsible for managing staff access. Only authorized staff at your practice have access to health plan information for your patients.

*Required Field

*Required Field

NPI

NPI 10 digit National Provider Identifier null

Univera Provider ID

Univera Provider ID

Provider's Name

Provider's Name First and Last name null

Last Four Digits of Provider's SSN

Last Four Digits of Provider's SSN null

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number null

User's Name

User's Name First and Last name

User's Email Address

User's Email Address null

Do you already have a web account for this group?

Do you already have a web account for this group? null

Username

Username 5-8 numbers or letters, no symbols

1st Choice for Username

1st Choice for Username 5-8 numbers or letters, no symbols

2nd Choice for Username

2nd Choice for Username 5-8 numbers or letters, no symbols

We are 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.

We are 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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GDPR Notification Content