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USER MAINTENANCE REQUEST FORM
Entity Provider Name: ______________________________ Entity Tax ID Number: ____________
Affiliate Provider NPI:________________________________(Optional)
Please add the following users for Blue e access:
User Information (for Blue e access)
User Name
Job Responsibility
(First, Middle Initial, Last)
(e.g., Registration, Billing, Human
Resources, EFT*)
User Email Address
*Please see the amended Blue e Network Agreement online for directives about users with EFT
access.
Please delete the following users from Blue e access:
User Name
(First, Middle Initial, Last)
User Name
(First, Middle Initial, Last)
Requestor’s Name: _______________________________________________________________
Requestor’s Phone Number: ________________________________ EXT. __________________
Requestor’s Fax Number: __________________________________________________________
Requestor’s Email Address (required for confirmation):____________________________________
________________