Upload a Third-Party Authorization form

If you're an authorized third party, you must include a Third-Party Authorization form (also called a Billing Agency Access Form or a Provider Entity Authorization Form) when you first register with NaviNet, or when you add tax IDs or health plans to your office.

We don't accept Third-Party Authorization forms via fax or email.

  1. Download and print the form. When you register with NaviNet, or when you add tax IDs or health plans to your office, we provide a link for you to download the authorization form. You can also download the Third-Party Authorization Form here.
  2. Complete the Third-Party Authorization Form for each of your requested tax IDs.
  3. Provide the following two required signatures. We don't accept electronic signatures—they must be signed manually.
    • One signature from a third-party employee.
    • One signature from a NaviNet security officer at the provider entity/office. (A third-party employee cannot sign on behalf of the provider entity/office.)
  4. Upload your completed form to your NaviNet case.