Allscripts Facility Master File

Allscripts Facility Master File
Complete this request form when a new facility must be added to the system. All information is required unless otherwise noted and must be complete for this request to be honored. This form can also be used to request a change to an existing record by noting the information that is to be revised. If the facility has a provider number that must be present for insurance billing, please use the Provider Numbers request form and submit it along with this request.
Facility Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone-Main

Area CodePhone Number
Phone-Alternate:

Area CodePhone Number
Fax:

Area CodePhone Number
If request is for more than one Facility please upload spreadsheet with required information here:

Upload a File

Cancelof
Facility Type: Proper billing is dependent on this information. Those choices with an asterisk require additional information for Facility Usage.
What needs to happen with this Facility:
Check what applies:
Additional Facility Usage Requirements
Office:
H-Hospital - please check all that apply:
N-Nursing Home-please check one:
RB-Rehabilitation Facility - please check one:
HPSA Facility?(AQ modifier needed for Medicare,Railroad Medicare,Tricare)
Other facility identification numbers may be necessary for proper billing. Please complete any information that pertains to your request.
Mammography Certification Number:
CLIA Number:
NPI Number:
Special Instructions:
Submitted By:

First NameLast Name
Date:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Internal Use
Status:
Status Details:
Vision Request Completed By:

First NameLast Name
Date:

MonthDayYear
Enterprise Completed By:

First NameLast Name
Date:

MonthDayYear
Vision Use Only
Vendor Notified
Patricia Cochran Notified if applicable for update in EPIC?(pcochran@stfranciscare.org)
Should be Empty:

Allscripts Facility Master File

Vision Use Only