HOME
CONTACT
SUPPORT
SUPPORT OVERVIEW
REQUEST SUPPORT
SUPPORT DOCUMENTS
FEATURE REQUEST SUBMISSION
SUPPORT ALERTS & ADVISORIES
Add a Provider
Please allow 3-5 business days for response.
Customer/Practice Information:
*
CUSTOMER NAME:
*
CONTACT NAME:
*
DIRECT TELEPHONE:
BEST TIME TO CONTACT:
*
E-MAIL:
*
FAX :
*
CUSTOMER ADDRESS:
New Provider License Information:
*
NAME OF NEW PROVIDER:
(please make sure to include credentials, ex. MD, DO, NP, PA-C, etc)
*
AVERAGE SCHEDULED WORK HOURS PER WEEK:
HOURS
*
PROVIDER BILLING INFORMATION:
Group Tax ID
Individual
Tax ID
Bill under another
Provider Tax ID
No Billing
*
EFFECTIVE DATE OF NEW PROVIDER:
(this is the date the new provider
must
be active in the system – this may vary
from the provider’s actual start date should scheduling be required in advance)
COMMENTS:
