New Provider Profile Information

New Provider Profile Information
Group/Practice Information Section
Listed below are a few necessities that will be needed for our Implementation Team to build your Practice in the NextGen System. During your training, we will refer to these items and what roll they play to the overall success and operation of your Practice. Should you not be able to supply this information prior to your Go-Live date, there may be a delay until all necessary information has been loaded.
- Please complete this form for each additional location if needed.
- Location
- Name of Practice*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Location Phone#*
  Format: (000) 000-0000.
- Secondary Phone#*
  Format: (000) 000-0000.
- Fax#*
  Format: (000) 000-0000.
- Email Address*
  example@example.com
- Primary Contact Name*
  
  First NameLast Name
- Title*
- Contact Phone#*
  Format: (000) 000-0000.
- Extension#*
- Secondary Fax#*
  Format: (000) 000-0000.
- Back Line Phone#*
  Format: (000) 000-0000.
- Contact Person's Email Address*
  example@example.com
- Other Contact Person*
  
  First NameLast Name
- Title*
- Phone Number*
  Format: (000) 000-0000.
- Extension#*
- Fax#*
  Format: (000) 000-0000.
- Email Address*
  example@example.com
- Type of Practice/Specialty*
- Practice/Group State License#*
- Practice/Group Federal Tax ID#*
- Practice/Group NPI#*
- Practice/Group Taxonomy*
- Practice/Group EZ-Cap/Oasis#
- Please complete this section for one provider only
- Provider Name (as listed on License)*
  
  First NameLast Name
- Provider License Status*
- Title*
- Practice Name*
  If provider is part of a Group, see Group Information sheet for more details
- Type of Practice/Specialty*
- EnglishOther
- Provider State License#*
- Provider Federal Tax ID#*
- Provider Social Security#*
- Provider DEA#*
- Provider Taxonomy*
- Provider NPI#*
- Provider LabCorp ID#*
  Enter Group# if part of Group
- Provider OASIS EZ Cap#
- Provider Primary Contact#*
  Format: (000) 000-0000.
- Provider Mobile/Cell#*
  Format: (000) 000-0000.
- Fax#*
  Format: (000) 000-0000.
- Email Address*
  example@example.com
- Select all that applies
- AdmittingFirst ConsultingSecond ConsultingReferringOther
- YesNo
- Supervising Physician
  Complete this is Supervision is required
- If other practicing locations are used, please list all service locations below. If more than one additional location is used, please complete the Additional Service Location section.
- Location#*
- Facility/Location Name*
- Location Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Location Contact Name*
  
  First NameLast Name
- Title*
- Contact Phone#*
  Format: (000) 000-0000.
- Location Phone#*
  Format: (000) 000-0000.
- Location Fax#*
  Format: (000) 000-0000.
- Location Email Address*
  example@example.com
- Location NPI#*
- YesNo
- Only complete this section if the provider is practicing at addional locations
- Location#
- Facility/Location Name
- Location Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Location Contact Name
  
  First NameLast Name
- Title
- Contact Phone#
  Format: (000) 000-0000.
- Location Phone#
  Format: (000) 000-0000.
- Location Fax#
  Format: (000) 000-0000.
- Location Email Address
  example@example.com
- Location NPI#
- Select all that applies
- California Nursing and Rehabilitation, Palm Springs, CACarlotta Retirement and Care Center, Palm Desert, CACountry Villa Rancho Mirage Healthcare, Rancho Mirage, CADesert Hospital Hospice, Palm Springs, CA
- Desert Regional Medical CenterOut PatientAcute RehabERIn PatientEl Mirador
- Eisenhower Medical CenterOut PatientERIn PatientKidney Institute
- Hi Desert Continuing Care CenterHi Desert Medical Center
- Hi Desert Memorial HospitalOut PatientTransitional Care Unit
- Hope Square Surgical CenterIndio Nursing HomeInner Image Center
- John F Kennedy Memorial HospitalIn PatientOut Patient
- Manor Care Nursing CenterMulcare Skilled Nursing CenterPremier Rehab Nursing Center
- Should be Empty: