MARx's Request Form

First Name *

Last Name *

Phone

Email *

Agency Name *

Humana SAN *

Agent NPN *

What type of MARx request ?

New Request-No Previous Access

Recently Lost Access

Need Help Updating Sponsor Code

Have you completed the training called "Compliant Use of the MARx System" or "MARx System Training?"

Yes

No

MARx Training Completion Certificate

Please upload proof of completion

Training To Be Assigned.

You will be assigned training. Please allow up to 10 business days for training issuance in MarketPoint University.

Click the above option to acknowledge before sumission

In your CMS user profile, have you made a request for contract H1036, selecting MAPD Agent for Role?

Yes

No

This is required. Please make the request for H1036. Role is MAPD Agent.

Contract H1036 has been requested

Click the above option to acknowledge you have requested Contract H1036 before sumission.

Required - Provide the MARx Request Tracking Number:

Thank You

We are processing your request. CMS will notify you upon approval or rejection.

Click the above option to acknowledge before sumission.