IPA Name Change Request Form

IPA Name Change Request Form

This form is not for New Provider Request
***NOT FOR NEW PROVIDER REQUESTS***
Date of Request*

MonthDayYear
Date
Practice Contact Information
NOTE: ALL FIELDS ARE REQUIRED FOR PROCESSING
Practice Name:*
Contact Name:*
Contact Phone Number:*
Email Addr. / FAX Number:*
AS STATED IN THE CID SYSTEM SERVICES AGREEMENT, EXHIBIT 2, EACH AUTHORIZED PROVIDER LICENSE ALLOWS FIVE (5) AUTHORIZED USERS TO UTILIZE THE SYSTEM. THIS IS DEFINED AS HAVING ACCESS TO FIVE UNIQUE USERNAMES AND PASSWORDS. REQUESTS FOR USERNAMES IN EXCESS OF THE FIVE ALLOTTED, ARE SUBJECT TO A MONTHLY PER USER PASS THROUGH CHARGE, TO BE CHARGED TO THE CONTRACTED PROVIDER.
(For Name Change Only)*

OLDNEW
PLEASE ALLOW UP TO (2) BUSINESS DAYS FOR ALL REQUEST TO BE PROCESSED
*Note: CID policy requires up to 2 business days (not including weekends) for all User Change/Request to take place upon the receipt of this signed form. Change Request are scheduled Mon-Fri between 8am and 5pm, Request performed over weekends by special request only. Please contact CID Support at 760-320-8814 ext. 1700 or TechSupport@MYDOHC.com for more information. **All request/changes must be in writing using this form, and must be faxed directly to CID Support at 760-323-1391 or DOHC at 760-323-8674 (See Special note). It is the responsibility of the authorized requestor to ensure that all users who may be affeccted by this change are notified that the change will be made. Any potentially affected systems, software, hardware, or procedures should be evaluated for the effect of the change upon them, and plans made for remediating any effecct and "backout" any changes. No change will be scheduled or implemented until a change request form signed by an authorized requestor is received. CID will make every effort to accommodate this request in the time frame requested, but will schedule changes when possible during a regularly scheduled maintenance window. Please call 760-320-8814 ext. 1700 with any questions.
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