Allscripts Provider / Referring Doctor Master File

Allscripts Provider / Referring Doctor Master File
Complete this form when a new provider or a referring provider must be added to the system. Your provider may need to be SFHCP authorized for Alls system usage. Please contact the SFHCP Administrative Office to verify prior to submitting this request. In the event the user needs a login for Alls Enterprise created, please also complete the "Alls Login Security Master File". If you need a schedule added to Vision for this provider and require assistance, please complete the Alls Schedule request form as well.
Type:
Select one:
Effective Date:

MonthDayYear
Provider's Group Code:
Provider's Facility Code(s):
Provider's Department Code if used(N/A if not):
Provider Information
Provider name:

First NameMiddle IntlLast Name
Does this user have an AD account:
If yes Please indicate AD login name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:

Area CodePhone Number
Fax:

Area CodePhone Number
Specialty:
Provider NPI:
Title
Group Medicaid Taxonomy Code:
Provider Taxonomy Code-required for billing providers:
Tax ID # - required for billing providers:
Provider Medicaid Taxonomy Code(s):
CLIA#:
If request is for multiple users please upload spreadsheet with all required information here:

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Is this provider allowed to bill for services:
Does this provider have a Vision Login:
Special Instructions:
Submitted By:

First NameLast Name
Date:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Vision Setup data attached.

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Internal Use
Status:
Status Details:
Vision Request Completed By:

First NameLast Name
Date:

MonthDayYear
Enterprise Request Completed By:

First NameLast Name
Date:

MonthDayYear
Facility Code:
Doctor Code:
Referral Code:
Vision Use Only
Vendor Notified
Patricia Cochran Notified if applicable for update in EPIC?(pcochran@stfranciscare.org)
Click to edit

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Should be Empty:

Allscripts Provider / Referring Doctor Master File

Vision Use Only