Interpace Physician Portal

Account Change Request

Please complete the form below to request changes to an existing Interpace Physician Portal account.

If you are looking to register a new account, please use the registration form.

Changes Requested by:
Institution Information (Current Account)
Physician Information (Current Account)
Please specify this information as it is currently in the portal so we may identify your account.
Authorizer (Current Account)
Account Changes
Please complete the following fields with the updated information.
Disable Account
Institution Information (New Information)
Physician Information (New Information)
Additional Location #1
Additional Locations
Additional locations can be added only for Physician accounts. To update a location for an Institutional account, please do so within “Update Physician and Practice or Institution Information”.
Additional Location #2
Primary Contact (New Information)
Authorizer (New Information)
Authorizers are needed only for Institutional accounts
Institutional accounts require an authorizing director. Please select below.
Delegate #1
Delegate #2
Delegate #3
Delegate #4
Delegate #5
Finalize Request

Click the "Submit Request" button below to complete the request.