<p> Centricity Business Scheduling Provider Request Form</p><p>REQUESTOR</p><p>Select Activity: Add Service Request (SR) #: </p><p>Full Name: (Blank) Last Name Title First Name MI</p><p>For Edits Only: Numeric Code: Mnemonic: Scheduling Dept(s): (D301) </p><p>Pre-Scheduling Message: </p><p>Post-Scheduling Message: </p><p>Corresponding Billing Provider(s): (from Existing Billing Providers) (D3) Complete only for Physician Extenders and Residents.</p><p>Provider Category (Sched):(Blank) Reporting Credentials: Blank</p><p>Default Location(s): (This field should be left blank for multiple locations) (D331) </p><p>Non-Billing Provider?: N (This must be answered NO if this provider is to appear on the Missing Charge Report)</p><p>Phonetic Spelling for Call Reminders: Is this a PCP?: N </p><p>Corresponding Billing Location for Sched: (This field should be left blank for multiple locations) (D100) </p><p>Corresponding Billing Area: (D202)</p><p>Visit Types * If this is a new visit type for the Department, please complete the Scheduling Department/Visit Type Request form</p><p>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</p><p>Visit Type: Duration: </p><p>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</p><p>Visit Type: Duration: </p><p>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</p><p>Visit Type: Duration: </p><p>Use Call Reminder Existing Department Script: Y </p><p>COMMENT SECTION: </p><p>Administrator: Date: </p><p>Revised: 08/01/14</p>