First Name *
Last Name *
Email *
TIN (tax ID number) * See format requirement below
Please fill out this field.

type n/a if you are not a care provider
State *
Preferred Primary Specialty *
Role *
Please fill out this field.
NPI Number *
type n/a if you are not a care provider
Organization Name *
type n/a if it doesn't apply to you
Interests *
You may select more than one interest if preffered.
Advanced Notification / Prior Authorization
Claims Information
Medical Policy Updates
Pharmacy Updates
EDI Productivity Tools
Exchange Plans
UHC Provider Portal
Veterans Affairs Community Care Network (VA CCN)
Surest Health Plan
Fields marked with an asterisk * are required

Tax ID # must be submitted as only 9 digits with no additional characters or spaces.
If more than one Tax ID # is applicable, please submit each 9-digit tax ID # separated by a comma
with no additional spaces or characters. For example: 123456789,02345678