Form Uef - User Enrollment Form 2009
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1Kaiser Permanente Provider Web Site User Enrollment Form
Fax completed forms to Provider Relations: 1-216-479-5550
This Provider Web Site User Enrollment Form and a separate Web Site License and User Agreement must be
completed by each individual requesting access. Have your Enrollment Form & User Agreement authorized. Incomplete
forms can not be processed. Please complete one set of forms for each additional Tax ID number.
Section A. Contracted Provider/Group Information
Provider/Group/Practice Name:______________________________________________________________________
Group Address: __________________________________________________________________________________
__________________________________________________________________________________
Group Telephone Number: _______________________________________ Tax ID # : _________________________
Must Be Provided
Section B. Individual User/Enrollee Information
Your Last Name: _________________________________________________________________________________
Your First Name: ________________________________________________________ Middle Initial: _____________
Last 4-digits of your Social Security Number: _____________________ Date of Birth: __________________________
This information is required for initial user set up and will be used to confirm your identity should you call us regarding your user account.
Your Office Address: ______________________________________________________________________________
(If different from Group Address above)
Department Name, Location or Suite: ________________________________________________________________
Your Office Telephone Number: _____________________________ Your Fax Number: ________________________
Your Office Email: ________________________________________________________________________________
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NO
Licensed or Certified Medical Professional? YES
If yes, Credential: _______ Your NPI:_________________
(If Applicable)
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NO
Will you need the ability to submit referral requests online?
YES
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NO
Are you required to access patient clinical/medical records in order to perform your job duties? YES
Which of the following best describes your job, position or role with the participating Provider/Group you indicated in
Section A?
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Physician
Nurse Practitioner
Physician Assistant
RN
LPN
Medical Assistant
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Office Manager
Practice Manager
Billing Staff
DME Vendor
Front Office Staff
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Lab
Radiology
Other: _______________________________________________________________
_______________________________________________________
_____________________________
Enrollee/User Signature
Date
Name & Title of Your Immediate Supervisor: ____________________________________________________________
Supervisor’s Telephone: ________________________ Supervisor’s Email:
____________________________________________
Section C. Contracted Provider’s Acknowledgement & Authorization
The signature and printed name of a Physician, Management and/or Site Administrator is required on all Enrollment Applications.
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I confirm that this individual is employed or contracted by this practice/facility in the capacity indicated;
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I authorize Kaiser Permanente to grant this individual access to KP HealthConnect Online-Affiliate;
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I acknowledge that the Web Site contains confidential, protected personal health information; and as such,
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I, or my designee, will immediately notify Kaiser Permanente should this individual’s employment or contractual relationship with this
practice/facility terminate, voluntarily or involuntarily.
Authorizing Signature: ________________________________ Print Name: _______________________
Physician, Management or Site Administrator
Form UEF Ohio Revised 10/09
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Parent category: Business