Application for the Provider Report Portal

Important Note: This application has restricted use. If you want to receive duplicate remittance advice (RA) statements, please click here to complete the Application for Duplicate Remittance Advice (RA) Statement.

This application constitutes an agreement between Neighborhood Health Plan of RI (Neighborhood) and its affiliated professional or institutional provider, as identified below, to gain secure access to the Neighborhood Provider Portal. Access will be given to a designated Master Keyholder (ex: Security Officer) who will be responsible for adding and managing additional users. The Master Keyholder has the ability to view all reports and will manage assignment of reports to users. Upon set up the Master Keyholder will receive an e-mail with a secure link to this portal with instructions. The Back Up Master Keyholder set up is required in the event the Master Keyholder is unavailable.
Application*
Application *
- New Application
- Revised Application
Business Name*
Master Keyholder Information
Master Keyholder Name*
First Name Last Name
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
E-Mail Address*
Back Up Master Keyholder Information
Back Up Master Keyholder Name
First Name Last Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
E-Mail Address
Master Keyholder Authorization
Master Keyholder Authorized Signature (Use your mouse or touchpad to “sign” for authorization.”)*
Print Name*
First Name Last Name
Title*
Signature Date*
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