New/updated Office Information Sheet printable pdf download

New/Updated Office Information Sheet

Office Information

Provider Name: ________________________________________________

Address: _____________________________________________________

City: __________________ State: __________

Zip: ________________

Phone: _______________________ Fax: _________________________

Group Tax ID (list all doctors’ tax IDs at bottom): _____________________

Primary Contact Information (SuperUser)

Contact Name: _________________________________________

E-mail: _______________________________________________

Phone: _______________________________________________

Backup Contact Information (backup SuperUser)

Contact Name: _________________________________________

E-mail: _______________________________________________

Phone: _______________________________________________

Doctor Taxpayer Identification Numbers associated with this office:

____________________________________________________________________________

Staff Names (first and last):

Please note any staff members that have previously been issued a

Health Connect User ID.

____________________________________________________________________________

If you have any questions regarding this form call the Renown Health Help Desk at 775-982-4042.

Authorized Signature: __________________________________ Date: ____/____/______

(Owner, Provider or Legal Representative)

Print Name: _________________________________ Phone #: (_____) ________________

** An authorized signature can be that of a physician/provider, owner, CEO, chairman, director, attorney,

etc. If there has been an appointed designee (a SuperUser) within your organization, that person may

sign this form as well. Forms without the signature of a legal representative of the office will be denied.

Forms may be faxed in, in lieu of the mailed in copy of the original signatures. **

Fax completed form to: 775-982-3751

New/updated Office Information Sheet