Provider Communications Email Sign-up Form

Complete this brief form to receive the latest news and information of interest to the Independence Blue Cross (Independence) provider community.
Note: This form should only be completed by participating providers. If you are part of an Integrated Delivery System (IDS), please contact your Network Coordinator for Independence news and information.

Email Recipients Information (* required fields)

*First name:
*Last name:
*Email address:

Office/Company Information

*Company name:
*Street address 1:
  Street address 2:
*State: *Zip Code:
  Phone number:
  Name of person completing form:
To ensure your privacy, all information will be sent via a secure connection. Independence will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.
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