super testy testy

Location
Practice & Group
Specialty
Business Fax
Clinic Phone
CO License Original Effective Date
CO State License Expiration Date
CO State License Number
Fax Date/Time Validated
First Name
Form Submitter's Name and Position
Last Name
Mailing City
Mailing State/Province
Mailing Street
Mailing Zip/Postal Code
Middle Name
NPI
Preferred Communication
Professional Suffix
Type
UPI Out of State License Expiration Date
UPI Out of State License Issuance Date
UPI Out of State License Number

Epic to Test

University of Colorado Health  

External Provider Information Form

If you have any questions about this form, please contact the Health Information Management Team at 720-848-6148.

Provider Type:--None-- Advanced Practice Nurse Athletic Trainer Audiologist Certified Nurse Midwife Certified Registered Nurse Anesthetist Chiropractor Clinical Nurse Specialist Counselor Dentist Hearing Instrument Specialist Licensed Acupuncturist Licensed Clinical Social Worker Licensed Practical Nurse Licensed Psychologist Midwife Naturopathic Doctor Nurse Practitioner Occupational Therapist Ocularist Optometrist Pharmacist PhD Doctor of Philosophy Physical Therapist Physician Physician Assistant Podiatrist Registered Dietitian Registered Nurse Resident Speech and Language Pathologist
Individual Provider NPI:
First Name
Last Name
Middle Name:
Professional Suffix:DO MBA MD PhD AA ACNP ANP ANP-BC ANP-C AOCNP APN APNP ARNP ARNP-C AT AUD BCO CCC-A CFNP CNM CNP CNS CPM CPNP CRNA CRNP DC DDS DMD DPM DPT EdD FNP FNP-BC FNP-C FPMHNP LAC LCSW LPC LPN MA MPH MSPT MSW ND NNP NNP-BC NP NP-BC NP-C OD OT Other OTR PA PA-C PharmD PMHNP PNP PsyD PT RD RM RN RPA-C SLP WHNP
Provider Specialty:
Clinic or Practice Name
Mailing Street:
City
State/Province
Zip:
Preferred Communication:--None-- Fax
Work Phone:
SECURE Office Fax:

CO License Original Effective Date:
CO State License Expiration Date:
CO State License Number:

UPI Out of State License Number:
UPI Out of State License Issuance Date:
UPI Out of State License Expiration Date:

Form Submitter's Name:
Submitter's Title or Position:

By clicking Submit Query below, you agree that:
The fax machine receiving Protected Health Information is located in a secure area that is not accessible to the public or to those who do not need to know the information.
If any of your contact information changes, you must resubmit this form.  In accordance with the HIPAA Privacy Standards, if you do not promptly report changes, you may be held liabel for any patient information which has been divulged.  If you have questions, you can contact the Health Information Management Team at 720-848-6148.



Lead Source External Provider Info Update

EPIC Update July 9 2015

University of Colorado Health  

External Provider Information Formm

If you have any questions about this form, please contact the Health Information Management Team at 720-848-6148.


Provider Type--None-- Advanced Practice Nurse Athletic Trainer Audiologist Certified Nurse Midwife Certified Registered Nurse Anesthetist Chiropractor Clinical Nurse Specialist Counselor Dentist Hearing Instrument Specialist Licensed Acupuncturist Licensed Clinical Social Worker Licensed Practical Nurse Licensed Psychologist Midwife Naturopathic Doctor Nurse Practitioner Occupational Therapist Ocularist Optometrist Pharmacist PhD Doctor of Philosophy Physical Therapist Physician Physician Assistant Podiatrist Registered Dietitian Registered Nurse Resident Speech and Language Pathologist
Individual Provider NPI
Last Name
First Name
Middle Name
Professional SuffixDO MBA MD PhD AA ACNP ANP ANP-BC ANP-C AOCNP APN APNP ARNP ARNP-C AT AUD BCO CCC-A CFNP CNM CNP CNS CPM CPNP CRNA CRNP DC DDS DMD DPM DPT EdD FNP FNP-BC FNP-C FPMHNP LAC LCSW LPC LPN MA MPH MSPT MSW ND NNP NNP-BC NP NP-BC NP-C OD OT Other OTR PA PA-C PharmD PMHNP PNP PsyD PT RD RM RN RPA-C SLP WHNP
Provider Specialty
Clinic or Practice Name
Mailing Street
City
State/Province
Zip
Work Phone
SECURE Office Fax

CO State License Number:
CO License Original Effective Date:
CO State License Expiration Date:

UPI Out of State License Number:
UPI Out of State License Expiration Date:
UPI Out of State License Issuance Date:

Form Submitter's Name:
Submitter's Title or Position:

By clicking Submit Query below, you agree that:
The fax machine receiving Protected Health Information is located in a secure area that is not accessible to the public or to those who do not need to know the information.
If any of your contact information changes, you must resubmit this form.  In accordance with the HIPAA Privacy Standards, if you do not promptly report changes, you may be held liabel for any patient information which has been divulged.  If you have questions, you can contact the Health Information Management Team at 720-848-6148.




Lead Source External Provider Info Update

web to lead for EPIC

First Name
Last Name
Email
Company
City
State/Province
Fax
Secondary Language(s):English Spanish French Russian Arabic Chinese German Japanese Portuguese Hindi/Urdu
Patient Status:--None--New Existing

First Name
Last Name
Email