Allscripts Provider Numbers Master File

Allscripts Provider Numbers Master File
Please provide insurance carrier, number, and effective date, and indicate if number is for a Facility, or an Individual, or Group by circling the appropriate response. Each provider should be submitted on a separate form. If original carrier paperwork is available, please include a copy. This form can also be used to request a change to an existing record by noting the information that is to be revised.
Group (Code):
Provider:
Facility:
Carrier Name and Number:
Name/Number:
Type:
Effective Date:

MonthDayYear
Name/Number:
Type:
Effective Date

MonthDayYear
Name/Number:
Type:
Effective Date:

MonthDayYear
Name/Number:
Type:
Effective Date:

MonthDayYear
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
Should be Empty: