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May 29, 2025

*= Required Field

User Account:
* User Name:
User name must be at least 6 characters
Example: john44
* First Name:
* Last Name:
* Email Address:
* Phone: 
* Password:
Password must be 8 or more characters
* Confirm Password:
Account Status:  Active    Inactive  
 Any password entry will force the user to change their password upon next sign on.
User Access
 Claim Status Inquiry
 Benefits & Eligibility Inquiry
 View & Print Billing Invoices
 Claims Detail Information - HIPAA
 Online Enrollment
Groups this account accesses:
  FULLY INSURED20883-000-00000-28011
03000-00 
   SELF INSURED INDIVIDUAL93705-000-00000-00000
  FULLY INSURED JOINT03905-000-00005-00000
  FULLY INSURED JOINT40013-000-00000-00000
  VISION40001-000-00000-00000