Authorization Provider PortalAccess Request

*This request is for the authorizations provider portal.

**Please back out of this page if you are looking for access to the claims provider portal.

First Name

Last Name

Access Request Email

Best phone number to reach you at:

This phone number will be used if a reviewer needs to contact you about your authorization.

Phone

Clinic/Company

Approving Supervisor

Approving Supervisor Email

Authorization NPIs for your clinic/practice and/or your providers (please separate with commas or attach a file below)

If attachment is provided, write "See attached" below.

Authorization NPIs for your clinic/practice and/or your providers - File Upload

Drop your files here

Comments

Terms and Conditions

The user rights assigned to you authorize you to access confidential patient information. Use is granted for the purpose of requesting services for eligible members.

Your use of the Provider Portal indicates that you will adhere to all HIPAA laws regarding Protected Health Information (PHI) and use professional judgment and respect with all information you access. PHI contained within the Provider Portal is HIGHLY CONFIDENTIAL and intended for the exclusive use of authorized providers of Cascade Health Alliance.

Your login information is unique to you. Sharing your login information with others is strictly forbidden.

Violation of these terms will result in disciplinary action, including revocation of Provider Portal access. Checking the box below indicates that you have read and understand these terms and accept the responsibilities associated with Provider Portal access.

I accept these terms

Send me a copy of my responses

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