State Health Plan Health Benefit Representative Contact and Access Request

First Name

*

Group Name

Last Name

*

Mailing Address 1

*

Job Title

*

Mailing Address 2

*

Email Address

**

*Please ensure that the email address entered is correct before submission.

Mailing City

*

Primary Phone Number

*

Mailing State Abbreviation

*

Secondary Phone Number

*

Mailing ZIp Code

*

Group Health Benefit Representative Access and/or
Contact Request Submissions

Please note: This form is not intended to be used by employees who need to enroll in benefits - only for Benefit Administrators or Group Health Plan Contacts.

Type of Request Being Submitted

General HBR and Group Information

System Access Requested:
(only select access required to perform job duties)

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:

https://www.shpnc.org/notice-privacy-practices

Group Health Benefit Representative Access and/or Contact Request Submissions

​​Please note: This form is not intended to be used by employees who need to enroll in benefits - only for Benefit Administrators or Group Health Plan Contacts.