Apply

APPLICATIONS

For a faster turnaround, complete the application online. 

• Individual application for coverage This link will take you to myPortal. To apply, please create an account under "New User Registration – Individual."
• Ancillary application
• Entity application

QUESTIONNAIRES

If you perform any of these procedures, please submit the appropriate questionnaires with your application.

• Bariatric
• Chiropractic
• Cosmetic
• Infusion Therapy
• Nurse Midwife
• Pain Management
• Podiatry
• Prenatal
• Telemedicine

FORMS

HIPAA-HITECH Business Associate Agreement
An agreement required by federal law concerning policies and procedures to assure the confidentiality of patient health information.