Login Request Form
Login credentials are needed to access the client portal, claim report system, and medical provider database. If you need a username and password, complete the form below. Upon validation of your request, you will receive your login credentials within 48 hours.
To optimize access to the claim status and/or to generate reports, use Internet Explorer.
Include the following information on the form below which will be sent as an email to: firstname.lastname@example.org
Fields marked with an * are required.