Small Group Employer Portal Request Form
Questions? Please call 1-877-293-7035 (group leaders) or 1-800-262-0821 (agents).
Please return completed form to EMPLOYER.PORTAL@BLUECROSSMN.COM (Please allow for up to 15 business days to process)
* Indicates a required field to process.
Client Information:
Client ID: Client Legal Name*:
Doing Business As:
Authorized Signer Name*: Authorized Signer Phone*:
Authorized Signer Email*:
Agency Access:
Please note, all agents of record of Client, as well as certain agency staff will automatically be enrolled to have modify access for member enrollment,
census reporting and view billing of the Client unless Client designates differently below.
If you DO NOT want your agent to have this access, please indicate below by checking the box.
I do not authorize my agent to have access to the following company data:
Billing
Member Enrollment/Census Reports
If you DO NOT want agency staff to have access, please indicate below by checking the box.
I do not authorize agency staff to have access to any company data.
___________________________________________________________________________________________________________
Individual User access to Employer Portal and Benefits Manager:
First & Last Name*:
Company Name*:
Address*:
City*: State*: Zip*:
Phone*: Email*:
Member Enrollment Access:
Access Type: View Modify None
Access to All Groups:
Yes No If No, access these group number’s only:
eBill Access:
Access Type to Billing Invoices: View invoices Pay invoices None
Access to All Billing Accounts:
Yes No If No, which billing accounts?
___________________________________________________________________________________________________________
Agreement:
Please read carefully before signing
I attest I am an authorized signer for the Client listed above. By signing this form, on behalf of the Client listed above, Client understands and
agrees to the following terms and will notify any assigned user of all terms stated below.
1. Client agrees to ensure designated
user will not share user id and/ or password with anyone.
2. Client agrees to ensure the designated user will use the Employer Portal and Benefits Manager Portal only as directed within their job function, and
only to the extent expressly authorized by Blue Cross and Blue Shield of Minnesota (Blue Cross).
3. Client agrees to ensure no sharing of any information obtained through the Employer Portal and Benefits Manager Portal with anyone unless required.
4. Client understands it will be held accountable for all actions performed within the Employer Portal and Benefits Manager Portal under any authorized
user id and password.
5. If this form is completed as an electronic form, both parties agree to conduct this transaction electronically.
6. The Client listed above, hereby designates the user as its authorized representative to directly receive Protected Health Information (PHI) from Blue
Cross. The Client and any authorized user are responsible for complying with the requirements of all applicable state and federal privacy laws,
including but not limited to HIPPA. Client shall immediately notify Blue Cross if a user is no longer allowed access through the Employer Portal and
Benefits Manager Portal or PHI access.
Client Authorized Signer Signature: _ Date:
Blue Cross
®
and Blue Shield
®
of Minnesota and Blue Plus
®
are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
F11142 (08/20)
