New Provider Request Form

New Provider Request Form

Please fill out all required sections on this form and submit

Please submit Request forms at least 2 weeks prior to Provider start date. MEDENT will complete the requested forms in order they are received. This will ensure your Provider is completely setup prior to their start date.

MEDENT Account Number:*

Directory (if multiple directories):

Estimated Start Date:*

(Date you want provider added to Masterfiles to start building schedules, etc)

Module Start Date:*

Modules are billed based on this date. This should be providers physical start date.

How many days per week does this provider work?*

MEDENT Provider#:

(Leave Blank & MEDENT will assign next available number or enter preferred Doctor #.)
Note: Deactivated doctor numbers cannot be re-used

Provider First Name:*

Provider Last Name:*

If this request is for a 'fake' resource type provider with only one name, please type N/A in the Last Name field

Provider Middle Initial:

Provider Credentials:

Provider Type:*

Specialty Code:

If unsure see websites or

Business Address:*




Business Phone # (must be in this format: xxx-xxx-xxxx) *


Fax # (must be in this format: xxx-xxx-xxxx):*

Location numbers where Provider will see patients:

Practice # (only if practice has more than 1)

Tax ID#:*





Group NPI#:*





DEA #:

Special Requests:

Will Charges be entered for this provider?*

Does this provider need a Default Supervising Doctor on claims?*

If Yes, please indicate the provider name and # to attach

Will provider need to be supervised when prescribing medication?*

Will provider be Referred to (incoming) or Referring Dr (outgoing)?*

Nurse's/Non-EP's Schedule:

(Provider Type, e.g., nurse, lab, etc. should NOT be included in the MIPS/PI incentive program.)

Ohio Nurse Practitioner/Physician Assistant ONLY CTP (Certified To Prescribe) #

Insurance Credentialing:

Do you need assistance setting the CR (Credentialed) and BA (Bill As) fields in the Ins Co Setup?*

Additional Information:

NY Medicaid:

Will this provider be billing claims to NY Medicaid?*

If Yes, do you need MEDENT to send you a Medicaid Certification form?

If Billing Carisk NYS Workers Comp:

Is this provider going to participate in Carisk?*

Have you registered your provider's credentials with the Worker's Comp Board?*

If you have not registered, an XML agreement will need to be completed on the website.

Do you need further assistance?*


Do you need assistance setting up the provider's scheduling templates?*

Will provider use the Surgical Book Planner?*

If using RevSpring Module, do you need assistance adding?*

If using Directlink, do you need assistance adding the provider to:*


Provider has been added as a user?*

**Please NOTE the new Doctor # needs to be linked in the User file, please call EMR Support if you need assistance with this.

What modules will the provider use:

Will the provider need assistance setting up Point&Click/Progress Note Templates?*

Is the provider participating in MIPS?*

Surescripts Identity Proofing Representative (Required if not doing EPCS):

All providers being setup on the Surescripts network for e-prescribing must go through an identity proofing process.

Providers doing Electronic Prescriptions for Controlled Substance (EPCS): Go to, click "Buy Now" and select the "IGC Basic Assurance Unaffiliated Hardware - EPCS Prescribing".

Upon completion of the ID proofing process, IdenTrust will send via mail, a letter to the provider's home. (They do NOT send this to the business). The provider must then fax (315-255-0230) or email that letter to the System Implementation department at You can use marker to cover up the account number and activations codes.

Providers NOT doing EPCS: The identity of the providers must be verified by an Identity Proofing Representative (IDPR) within the practice. The IDPR must be someone that has done Identity Proofing with IdenTrust (as described in Providers doing Electronic Prescriptions for Controlled Substance (EPCS) above or been appointed by someone in the practice that has done the Identity Proofing process. Note: If not doing EPCS at all, you can select the "IGC Basic Assurance Unaffiliated Software 1 Yr - Identity Proofing Only" option on the IdenTrust website.

It is the responsibility of the IDPR to verify the identity of the provider by way of a government issued ID card such as a driver's license then enter their name and sign below.

IDPR Authorized Name:


Please have the practice owner or practice administrator sign off on this form.

Authorized Name:*


Contact Person:*

Contact Email:*

Phone:* Ext: