Digital Services Request Form

Please use this form to submit requests for Digital (web) services. Your request will be routed appropriately. A team member will follow up with questions, if needed, or you will receive confirmation when your request is completed.

* Fields with an asterisk (*) indicates that this is a required field. Any item that does not contain an (*) you may leave blank.

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How to Manage Your Provider Profile 

Alaska, Montana and Washington (including Swedish) regions only.
  • Your clinic manager or other designated administrator can work with you to make updates and optimize your profile.
  • If you need access to manage your own profile, or if you are an administrator that needs access to manage provider profiles, you may request access to the profile database, called Kyruus ProviderMatch, by completing the profile request form. Login instructions will be mailed by Kyruus to the email you provide.
  • To have profile changes made for data fields that are not editable in ProviderMatch, please follow the ProviderMatch help text instructions for the data field you need to change. The help text will instruct you to either submit a work request or send an email to the provider directory team.