iEXCHANGE® Web Enrollment Form

Note: Provider includes Physician, Professional Provider and Facility Provider

(*) Indicates a required field.

* Provider / Office / Group Name:

* Tax ID:

* NPI Number:

* Primary Specialty:

* Assigned Administrator’s First and Last Name:

* Address (Location where services rendered):

* City / State / Zip Code:


* Contact Phone Number:

* Assigned Administrator’s Email Address:


Note: The iExchange Help Desk will email your iEXCHANGE ID, User ID and temporary password. Please allow five business days for processing.

Updated April 2018