Provider Portal Access Request First Name (required) Last Name (required) Your Email (required) Your Phone (required) Clinic Company (required) Approving Supervisor (required) Approving Supervisor Email (required) Authorized NPIs (please separate with commas) Upload NPI documents (optional) The user rights assigned to you authorize you to access confidential patient information. Use is granted for the purpose of requesting services for eligible members. Your use of the Provider Portal indicates that you will adhere to all HIPAA laws regarding Protected Health Information (PHI) and use professional judgment and respect with all information you access. PHI contained within the Provider Portal is HIGHLY CONFIDENTIAL and intended for the exclusive use of authorized providers of Cascade Health Alliance. Your login information is unique to you. Sharing your login information with others is strictly forbidden. Violation of these terms will result in disciplinary action, including revocation of Portal access. Checking the box below indicates that you have read and understand these terms and accept the responsibilities associated with Portal access. I accept these terms.