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
If you perform any of these procedures, please submit the appropriate questionnaires with your application.
- Infusion Therapy
- Nurse Midwife
- Pain Management
HIPAA-HITECH Business Associate Agreement
An agreement required by federal law concerning policies and procedures to assure the confidentiality of patient health information.