For Health Care Providers

Request for SIF to register your Administrator and issue the initial user name and password

Copy and paste the text below to your organization's letterhead. Replace the items in parentheses with your organization's information. List all SIF provider numbers the Administrator will need to access. (Your SIF provider number is located in the upper right corner of any EOB from the State Insurance Fund. It is NOT the same as your Federal Employer Identification Number, or tax ID number.) The initial user name and password will be e-mailed to the Administrator designated on the request. We cannot honor incomplete requests or requests that are not on your letterhead.

Please register our organization and establish the individual designated below as our Administrator:

(Organization name)

(SIF Primary provider number, NOT Federal Employer Identification Number)

(Designated Administrator - full name)

(Administrator’s preferred user name)

(Administrator’s e-mail address)

(Additional SIF provider numbers)

(Additional SIF provider numbers)

(Administrator’s telephone number)

Through my signature below, I warrant to the Idaho State Insurance Fund that I am duly authorized to designate the Web site Administrator for our organization and to grant them full access to our organization’s Explanation of Benefit and bill status information as displayed on the State Insurance Fund’s Web site. I understand our Web site Administrator will be able to grant access to other users to view our information and will have the responsibility to delete users who no longer require access to the information.

(signature)

(name)

(title)

(date)