Request for New/Update Referring Provider

* denotes required fields

What is the nature of the request?

What is the nature of the request? Add new Provider Reactivate or Update information on existing Provider
Name of submitter:
Phone number of submitter
Submitter email
Special Detail Notes:
New or Updated Referring Provider (Last, First, Middle)
Professional Degree (MD, PA, ARNP, etc)
Referring Provider Facility Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Office Phone Office Phone - ### - ### ####
Office Fax Office Fax - ### - ### ####
Personal Phone (Cell,Pager,etc) Personal Phone (Cell,Pager,etc) - ### - ### ####
Identification Numbers

At least one of the following identification numbers are required.
IMPORTANT!!!! If your facility has an interface with RAPC RIS/PACS please provide your EMR Provider ID number.

This is used in the interface mapping
Identification Number -NPI
Identification Number -UPIN
Identification Number -License
LIST ANY EXAMS THAT NEED TO BE UPDATED FROM "RAPC, REFERRING PROVIDER"

Please include Accession#, Patient Name, and Date of Exam for exams that need to be updated with this new provider.
Accession#
Patient Name
Exam Date
Accession#
Patient Name
Exam Date
Accession#
Patient Name
Exam Date
Accession#
Patient Name
Exam Date