Athena Provider Build Request Form

  • Athena Provider Build Request Form

    This form is to be completed when requesting for a new provider to be built in athena. This form is also to be completed when requesting for an existing athena provider to be added to an existing athena department. Once the completed form has been received, an Athena Analyst will contact you to determine the timeline based on priority, scope & resources.

  • Section A: Requester Information

  • Date of Request*
     / /

  • Section B: Provider Information

  • If adding an existing athena provider to existing athena department(s), select which type of departments:*
  • Provider currently credentialed at Saint Peter's Healthcare System*
  • Tentative Date of Credentialing*
     / /
  • Credentialing to be done with*
  • Provider will have/has privileges at Saint Peter's Healthcare System*
  • athena updates are sent to all users included in the “Athena Users” Outlook contact group. Indicate if this provider should be added to the “Athena Users” contact group*
  • Provider will be documenting within an athena encounter*
  • Provider will be placing orders in athena*
  • Provider will be performing procedures in the Same Day Surgery/2D Endoscopy Unit*

  • Section C: Billing Information

  • Type of Billing*
  • Provider is/will be billable in athena*
  • Provider will bill for services as a Supervising Provider under their name*
  • Tax ID/Provider group provider will be rendering services and billing under*
  • Allow missing slips to be generated for this provider upon appointment check-in*
  • Allow FIN number to be generated for this provider upon appointment check-in*
  • Employment Status Information*
  • Employment Type*
  • Office Practice Allocation Time at Saint Peter's > 10%

  • Section D: Quality Measures

  • Is the provider participating in ACO*
  • Provider to be enrolled in Quality Measures*
  • Provider to be setup for MIPs/MACRA*

  • Section E: Schedule and Communicator Setup

  • Scheduling template(s) to be built*
  • Allow provider to be visible in the athena Patient Portal*
  • Allow patients to schedule appointments under provider via the athena Patient Portal*
  • Allow patients to schedule appointments under provider via ZocDoc*
  • Allow automated Appointment ReminderCalls to be sent out for this provider via athena*
  • Upon receiving an automated ReminderCall, patients can “press 2” to reschedule their appointment either with with the practice staff or a LiveOperator. Indicate manner in which patient will be directed*
  • Enable Automated CareGap Calls*

  • Section F: Clinical Content Build Review

  • If clinical content build is required for this request, a separate meeting is to be scheduled with the requester and Athena Analysts.

  • Section G: SureScripts/Electronic Prescription Setup

  • Provider will be entering electronic prescriptions in athena*
  • Allow provider to receive automated electronic refill requests in athena*
  • Provider will be prescribing controlled substances in athena*

  • Section H: Provider Contact Information

    For "Professional Billing Providers" only - List provider’s preferred Saint Peter’s office contact information.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Section I: Department Selection

    Select departments that the provider will be rendering services under. In the dropdown list(s) below, start typing the department name(s) to narrow down the list. You may also scroll through and select the department(s) from the list. Multiple selections are allowed.
  • athena department(s) selected are currently using Phreesia for pre-registration/check-in*

  • Section J: Other

  • Tentative start date*
     - -
  • 0/160

  • Athena Signature Attestation Form: The Athena Signature Attestation Form will be sent via email upon submission of the form. The form is to be completed by clinical providers who document in athena and:

    • Will be signing orders (lab, imaging, prescriptions) in athena
    • Need their signature visible on an athena letter

    Refer to the instructions on the form regarding how to complete and submit the form.

  • Section K: IT Use Only

  • Should be Empty: