Provider Request Sheet

Centricity Business Scheduling Provider Request Form

REQUESTOR

Select Activity: Add Service Request (SR) #:

Full Name: (Blank) Last Name Title First Name MI

For Edits Only: Numeric Code: Mnemonic: Scheduling Dept(s): (D301)

Pre-Scheduling Message:

Post-Scheduling Message:

Corresponding Billing Provider(s): (from Existing Billing Providers) (D3) Complete only for Physician Extenders and Residents.

Provider Category (Sched):(Blank) Reporting Credentials: Blank

Default Location(s): (This field should be left blank for multiple locations) (D331)

Non-Billing Provider?: N (This must be answered NO if this provider is to appear on the Missing Charge Report)

Phonetic Spelling for Call Reminders: Is this a PCP?: N

Corresponding Billing Location for Sched: (This field should be left blank for multiple locations) (D100)

Corresponding Billing Area: (D202)

Visit Types * If this is a new visit type for the Department, please complete the Scheduling Department/Visit Type Request form

Primary Scheduling Department to copy associated Visit Types: Copy ALL Visit Types:  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Visit Type: Duration:

Secondary Scheduling Department to copy associated Visit Types (if applicable): Copy ALL Visit Types:  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Additional Scheduling Department to copy associated Visit Types (if applicable): Copy ALL Visit Types:  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Use Call Reminder Existing Department Script: Y

COMMENT SECTION:

Administrator: Date:

Revised: 08/01/14