If you are interested in signing up for HEALTHeNET application usage, please click on the “Request Form” link, and complete and submit the form. A HEALTHeNET representative will contact you within 5 business days of your request to provide further instructions and schedule training.

Request Form

These forms(PDF) are required to be completed for HEALTHeNET sign up

Please send completed forms to or HEALTHeNET, c/o PCI Help Desk, 703 Washington Street, Buffalo, NY 14203


Email Contact

Password and login support is not available through email. Your authorized contact must call the PCI Help Desk at 1-877-895-4724 for login support.