Upon receipt of this form, all information will be verified and the Site Portal Administrator user account(s) will be created.
The Administrator(s) will be contacted via the email(s), and be provided with a temporary password. The Site Portal Administrator will then create the User
IDs for appropriate practice staff to access the Portal.
The Site Portal Administrator reference guide is available on the Portal.
If you need assistance with completing this form, please contact your Provider Network Coordinator directly or the Provider Customer Service Line at 614-259-0286.