Alliance Claims System (ACS) Provider Portal Access Request

Alliance Claims System (ACS) Provider Portal Access Request
This form is to be used to request a login and password for access to the Alliance Claims System (ACS) Provider Portal. The form is also used to revoke an employeeʼs access that is no longer working with your agency. A member of senior management is required to complete, sign and submit the form.
1. Provider name
2. Contact name
3. Title(must be a member of senior management)
4. Direct phone
Format: (000) 000-0000.
5. Contact email
example@example.com

Please list the names and emails of folks in your organization who need access granted or revoked from the Alliance Claims System ACS