Add or Remove Ordering/Authorizing Provider - EpicCare Form

Add or Remove Ordering/Authorizing Provider Form
Name of Facility*
Add or Remove Provider*

AddRemove
Provider Legal Name*

Legal First NameLegal Last Name
Provider Credentials *
Provider Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Facility Contact Number*

Area CodePhone Number
Provider Facility Fax Number

Area CodePhone Number
Provider NPI*
User Email*
example@example.com
Sponsor Legal Name *

Legal First NameLegal Last Name
Sponsor Contact Number*

Area CodePhone Number
Sponsor Email*
example@example.com
Should be Empty: