Correctional Facility (Prison, Jail, RRC- Residential Re-entry Center)

Enter the name of the correctional facility where the patient was incarcerated at time of service.

Billing NPIs

Enter the Billing Provider NPI(s) submitted in Professional-Box 33, Institutional- Box 55, Dental- Box 49.

(Limit 6 NPIs per form. For additional NPIs, please submit another request.)

Do you need to enter multiple Billing NPIs?

Yes

Billing NPI Number:

Rendering Provider NPIs

If individual rendering NPI(s) listed, we will only add access to claims information for these rendering providers. If none listed, user will receive access to all rendering providers billing with the above billing provider NPIs.

(Limit 6 NPIs per form. For additional NPIs, please submit another request.)

Do you need to enter multiple Rendering NPIs?

Yes

Rendering NPI Number:

Users

First Name:

Last Name:

What would you like to do with this user?

Requested Password

Job Title/Position:

Phone Number:

Please include the full 10-digit number and extension if applicable.

Email Address:

Reason for access removal:

Other:

Reason for user inactivation:

Other:

Additional Information:

The full details of a ticket, including any appropriate circumstances or supplementary information that may aid in resolving it.

Attachment

File attachments associated with the ticket.

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Your name

Your email address

Your phone number

Provider Portal Access Request

Billing NPIs

Rendering Provider NPIs

Users

Other Fields