Health Benefit Representative Contact and Access Request

 Type of Request Being Submitted

 General HBR and Group Information

 System Access Requested:

 Subject Matter Contact Areas for Your Group?

 Previous Contact(s) You are Replacing for Your Group:

 Request Approver Information
 (must be Manager or Higher Level Person from your Group)

 Please provide any information that will help process this request:

To view the Privacy Practices of the NC State Health Plan please visit the link below: