INSURANCE PLAN INTEGRATION INTAKE FORM Instructions: Complete all sections below. For assistance, contact registry_tech_support@dlnys.org.Organization InformationInsurance Plan Name(Required)Parent Organization (if applicable)Primary Contact Name(Required) First Last Primary Contact Title(Required)Primary Contact Email(Required) Primary Contact Phone(Required)Technical Contact InformationTechnical Lead Name(Required) First Last Technical Lead Title(Required)Technical Lead Email(Required) Technical Lead Phone(Required)Technical Integration DetailsDo you offer an online member portal?(Required) Yes No Integration Type(s) (select all that apply)(Required) API SFTP If SFTP, Planned Data Exchange Frequency(Required) Daily Weekly Planned Weekly Transfer Day(Required) Friday Saturday Whitelisting Information: IP Address/Range(Required) Add RemoveList all IP addresses/ranges that will require access to Registry systems. Include both production and, if used, test/staging IPs. Enter one IP address/range per line. Add additional lines, if necessary, by clicking “+” next to field.Projected VolumePlease provide the most accurate available estimates or recent monthly averages for the following. Use approximate values where needed.New Insurance Applications(Required)Estimated Monthly VolumeInsurance Renewals(Required)Estimated Monthly VolumeNew Member Portal Accounts(Required)Estimated Monthly VolumeUnique Member Portal Users(Required)Estimated Monthly VolumeFor “digital vs. paper,” consider digital as all online portals, benefits platforms, mobile apps, or other non-paper channels; paper refers to mailed/faxed/manual forms. Type a whole number between 0 and 100 to represent a percentage (e.g., 100 for 100%).Digital Applications(Required)Estimated percentagePaper Applications(Required)Estimated percentageDigital Renewals(Required)Estimated percentagePaper Renewals(Required)Estimated percentageAdditional InformationPlease describe any special requirements, technical limitations, or any additional notes:
