OIC Provider Portal Access Request Form

Please provide the following information.
After completion an OIC staff member will process your request within two business days.

PLEASE NOTE: All users will be required to register a unique account on the Provider Portal. Usernames and Passwords will be assigned to each user and are not to be shared. Password will expire every 90 days.

You will be notified via the email provided below when your account has been created.

Name of Submitter (Account Holder) Name of Submitter (Account Holder) First Last
Email Address - You will receive notfication from OIC on the email provided here when your account has been created
Title/Role
Requesting Facility
Office Administrator Office Administrator First Last
Office Phone Office Phone - ### - ### ####
Office Fax # Office Fax # - ### - ### ####
Office Address Office Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please fill out the below section if your office is new to OIC's Provider Portal - if additional access to the portal is needed after initial office registration there is no need for the following field:
Referring Providers - Please list your office's referring providers (Last Name, First Name, NPI)

OIC Provider Portal Access Request Form

OIC Provider Portal Access Request Form

Please fill out the below section if your office is new to OIC's Provider Portal - if additional access to the portal is needed after initial office registration there is no need for the following field: