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New or Updated Referring Provider Request
Form Description
Request for an individual referring provider to be added or updated in CareConnect Ambulatory (Epic).
If you are using this form to update information that is incorrect in our system(s), please use the
Additional Information
field to help us understand what needs to be corrected.
For Place of Service (PeaceHealth) updates, please submit a
Cherwell Service Request
.
For Place of Service (Non-PeaceHealth) additions/updates, please use this
request form
.
Directions
Please complete the form below. Use the scrollbar on the right to move down the page. When finished, click the
Save
button located at the bottom of the form. Incomplete forms and/or incorrect information will delay processing.
Please do
not
include any patient information in this form as it is a HIPAA compliance issue.
Questions marked with a
red *
require a response.
Provider Name:
*
Last Name:
*
First Name:
Middle Initial:
Preferred First Name / Alias:
Provider Credentials:
*
License Type:
(MD, NP, PA, etc)
NPI #:
Format: 9999999999
Please look up NPI (individual, not organization) via this link:
https://nppes.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do
Provider User IDs:
Provider CareConnect (Epic) ID #:
Provider Centricity User #:
Is the Provider PECOS Enrolled?
Please select the date of PECOS verification:
PECOS Enrollment verified by :
Please state the name of the person who verified PECOS enrollment
Provider Contact Information
Provider's Practice Name:
Mailing Address:
*
City:
*
State:
Format: aa
ZIP Code:
Format: 99999
Phone #:
Format: 999-999-9999
Fax #:
Format: 999-999-9999
Additional Information:
Please provide any additional information:
Please do
NOT
include patient info in this form (MRN, patient name, etc.).
Requestor Contact:
If you are
not
at a PeaceHealth, HINet, or EHI hospital or clinic, please enter an email address for notification upon request fulfillment.
Without this email address, we cannot notify non-PeaceHealth requestors when the provider has been added.
Check this box if the request is urgent.
STAT Request
If you would like a copy of this completed form, please enter your email address.
Email:
