Health Benefits Portal

Provider Login Request

Please complete the following form to obtain a password

Website Password Issuance Form We are pleased to inform you that you may access information about our members at any time via our Website. This feature will allow you and your staff to access information regarding patient eligibility, to check the status of claims, and to view or print the No Pay Report. We will issue you a password-one for each TIN-which will permit you to access patient information contained in our Website. Please keep the password confidential to prevent unauthorized access to the personal health information of employees. This confidentiality is essential in order to comply with the privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA). In order to obtain your password, you must complete the form below. We will issue your password within two to three business days of receiving your request if you provide an e-mail address. Otherwise, you will receive your password via U.S. mail in four to five business days. If you have any questions, please contact the Operations Technology Department at (616) 957-1751, extension 5810. As always, it is our pleasure to be of service to you. NOTE: You must request a separate password for each TIN! Please complete the information below. * - Required Field

PROVIDER INFORMATION
Requester's First Name: *	* First Name Required
Requester's Last Name: *	* Last Name Required
Provider/Practice Name: *	* Provider Name Required
Tax Identification Number: *	Tax ID must be numeric * TaxId Required Tax ID must be 9 characters
NPI Number: *	* NPI Number Required
Mailing Address: *	* Address Required
Mailing Address 2:
City: *	* City Required
State: *
Zip Code: *	* Zip code Required
Telephone Number: *	Extension: * Telephone Required
E-mail Address: *	* Email Required
Confirm E-mail: *	* Email Required * Email addresses do not match.

AUTHORIZATION INFORMATION
By submitting this form, I am hereby requesting a password in order to access patient information on this website. I have read the above Notice of HIPAA Privacy Implications.