NaviMedix

NaviNet Request Form

To request access to NaviNet or to request an additional health plan, please fill out the following form. For all other inquiries, please use our general request form.

* required field

Organization Information:
Location Name*
Address 1*
Cannot be a P.O. Box
Address 2
City*
State/Province*
Zip*
Select if Mailing Address is Different than Above:

Contact Information:
Main Phone*
 x
Fax
Contact Person First Name*
Contact Person Last Name*
Contact Person Phone x
Contact Person Email*
Confirm Email Address*
Note: Adding an email address will expedite your request.

Requested Health Plan Information:
Does your office have access to NaviNet? Yes   No

Which health plans (if any) does this office already have access to?

(please select a state above to see health plans available to you)
Aetna
AmeriHealth
AmeriHealth Administrators
Blue Cross of Northeastern Pennsylvania
Cigna HealthCare
Dean Health Plans
Gateway Health Plan
Health Net
Health Net Federal Services
Highmark
Highmark Blue Shield
Independence Administrators
Independence Blue Cross
Mountain State Blue Cross Blue Shield
Rocky Mountain
SummaCare
UnitedHealthcare
Does your office have Internet access? Yes   No
Office Type
Is your office a billing agency?*
 Yes   No
Office Specialty*
Number of providers in your office
9-digit Tax ID*
no spaces or dashes
Confirm Tax ID*

Select the Health Plan(s) to which you want
NaviNet access:

(please select a state above to see health plans available to you)
(please type the zip code above to see health plans available in your area)

No health plans offer NaviNet in the area you entered. If you wish to learn more about NaviNet, continue filling out this form and submit it. We'll get in touch with you.

Aetna
AmeriHealth
AmeriHealth Administrators
Blue Cross of Northeastern Pennsylvania
Cigna HealthCare
Dean Health Plans
Gateway Health Plan
Health Net
Health Net Federal Services
Highmark
Highmark Blue Shield
Independence Administrators
Independence Blue Cross
Mountain State Blue Cross Blue Shield
Rocky Mountain
SummaCare
UnitedHealthcare
Other (enter plan names below)

Please enter health plans you would like to see available via NaviNet that do not appear in the previous section:

Enter in all Provider Names and Provider Numbers you need to view in NaviNet. We will be able to process your request faster if you enter your providers' names and IDs. Please separate ID numbers and names with a single space.
Limit to 5000 Characters | Remaining:

Additional comments on your request
Limit to 1000 Characters | Remaining:

NaviMedix