Health Information Exchange Request

Request Credentialing or Privileges

Please address the following issues:

First Name*

Last Name*

Direct Phone Number*

Email Address*

Organization's Name*

Organization's Website

Organization's Street Address*

Organization's City*

Organization's State*

Organization's Zip Code*

Organization's County

Alias or Previous Name

Title*

Provider Specialty*

Provider State License Issued*

Provider Date Of Birth (MM/DD/YYYY)

Provider NPI Number*

Provider License Number*

What facility are you requesting credentialing/privileges*

Please provide the city and state of the facility*