Driscoll Health Plan
Provider Portal Agreement

I, the undersigned, request access to the Driscoll Health Plan (DHP) Provider Portal on behalf of the provider office or facility shown below for the purposes of: (1) verifying DHP member eligibility, (2) verifying the status of claims submitted to DHP, and (3) other functionalities that may be provided in the future.
As part of this access, I acknowledge and agree to the following terms and conditions:

(1)	To assign a Portal Administrator to be responsible for adding, changing, and terminating portal access as staff turnover occurs for the staff and employees of this organization.
(2)	To ensure that terminated or resigning staff or employees shall have their access to the portal deactivated concurrent with their departure from our organization.

(3)	To ensure, with all reasonable and effective efforts, that the information contained in the portal will be treated as confidential and used solely for purposes authorized by applicable laws, rules, and regulations, including, but not limited to, the Health Insurance Portability and Accountability Act with regard to Personal Health Information.

(4)	To notify the Provider Relations Department immediately of a change in this organization’s assigned Portal Administrator.

(5)	Subsequent to initial set-up and training of applicable staff by DHP, to ensure that new or additional staff or employees given access to the portal by this organization are trained on how to use the portal using training materials provided by DHP.

Signed by:   	Date:	
Printed Name of Signer:	
Practice or Facility Name:	

Portal Administrator:	

E-Mail Address of Portal Administrator:	

Telephone Number of Portal Administrator:	

TAX ID: 

Fax completed form to 361-881-1349

Provider Portal Sign-up Information Form

The purpose of this form is to provide Driscoll Health Plan with the names and emails of your staff in order to create usernames for access to our Provider Portal (www.driscollhealthplan.com). In addition to accessing the site, your staff will be able to utilize various links based on your determination of need. If you need help with completing this form, contact Provider Relations at: 956-632-8308

Practice name:
Address:	
TAX ID:	
Phone#:	
Fax#:	
Primary Contact Person:	
Primary Email Address:	

To assure correct set up and easy access to the Provider Portal, please provide Driscoll Health Plan with the information below and return with your signed Web Access Agreement

 	

 	

Determine which access your staff needs:

Provider	Full access to the DHP provider Portal including member eligibility lookup; provider manuals; panel reports; claims search, submission and remittance advice (EOP) review; authorization search, submission and review; access to Vital Data; member service plans, SAI, ISP, and Order Sets; clinical review including flowsheets, allergies, histories, and chart review (as available); complaints and appeals information; access to electronic form submissions, authorization guides and quick reference tools; provider participation and credentialing information; provider and member resources; and provider tools and information
Back Office	Full access to the DHP provider Portal including member eligibility lookup; provider manuals; panel reports; claims search, submission and remittance advice (EOP) review; authorization search, submission and review; access to Vital Data; member service plans, SAI, ISP, and Order Sets; clinical review including flowsheets, allergies, histories, and chart review (as available); complaints and appeals information; access to electronic form submissions, authorization guides and quick reference tools; provider participation and credentialing information; provider and member resources; and provider tools and information

Front Office	Access to the DHP provider portal, including member eligibility lookup; provider manuals; panel reports; claims search, and remittance advice (EOP) review; authorization search and review; complaints and appeals information; access to electronic form submissions, authorization guides, and quick reference tools; provider participation and credentialing information; provider and member resources; and provider tools and information

Fax completed form to 361-881-1349
Provide the name and email for each user and identify which links they will need access to:

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

	Provider	Back
Office	Front
Office	
NAME				
EMAIL				

Fax completed form to 361-881-1349