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.

Provider Profile Information
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*
Languages Fluent In:*

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 Type/Role
Select all that applies
Type/Role of Provider*

AdmittingFirst ConsultingSecond ConsultingReferringOther
Supervision Required?*

YesNo
Supervising Physician
Complete this is Supervision is required

Other Service Location Information
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#*
Location Phone#*
Location Fax#*
Location Email Address*
example@example.com
Location NPI#*
Does Provider have additional Service Locations?*

YesNo