Physician Nurse / Staff

* Primary physician or clinic must be assigned access first.

Clinic/Medical Practice Group Name:

Staff Member Name:

Position/Job:

Telephone: - -

Email Address:

NPI (National Provider Identifier number) 10 digits:

* The NPI uniquely identifies each provider and can be used to identify the support staff for that provider. Please reference your Clinic/Group NPI or your primary physician's NPI for your access rights.

For User Verification

Alternate Key Contact (Clinic/Business Manager):

Alternate Key Contact Phone: - -

Alternate Key Contact Email:

If you wish to print this page for your records:

Send form electronically to Medical Records: