portal access request

Register for access to the tango Provider Portal.

Complete the form below to notify our network team to register your agency and requested user(s). Once registration is complete, you’ll receive an email with instructions to set up your password and access the portal.

With portal access, you can:
Request authorizations
Review authorization decisions and status
Verify member eligibility through tango

agency information

    requestor information.


    Contact First Name*

    Contact Last Name*

    Contact Phone*

    Contact Email*

    agency information.


    Legal Agency Name*

    DBA Agency Name (If Applicable)

    NPI Number*

    TIN Number*

    Home Health License Number

    address.
    Street 1*
    Street 2
    City*
    State*
    Zip*
    Phone*
    Fax* Fax number will be used to send authorization information, including PHI.

    Please upload your W9*

    Please upload your Home Health License