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Blue Cross and Blue Shield of Illinois
   
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iEXCHANGE Web User Enrollment Form

Note: Provider includes Physician, Professional Provider and Facility Provider.

 
* All Fields Are Required
Account Administrator's Name:  
Account Administrator's E-mail Address:  
Provider / Office Name:  
Provider / Office Specialty:  
National Provider Identifier (NPI) Number:  
Tax ID:  
Address:  
City / State / Zip Code: / /  
Contact Phone Number:
Please use the XXX-XXX-XXXX format.		  
Contact Fax:
Please use the XXX-XXX-XXXX format.		  

  

Note: The Illinois iEXCHANGE Help Desk will e-mail your Account Administrator your iEXCHANGE ID, User ID and temporary password. Please allow 10 business days for processing.
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