Provider request for a new provider in the ambulatory environment.
Example:
- Provider who works in an ambulatory office. A provider who works in an ambulatory office who also works/rounds at the hospital.
Use this form if Provider ONLY needs access to MModal.
To facilitate your request, here is the information we will need:
- Requested go-live date?
- Whether or not provider is employed by Covenant HealthCare
- If provider is employed by Covenant, is new hire process with payroll and HR completed?
- Providers specialty
- Will provider perform inpatient rounding at Covenant HealthCare?
- Any progress note templates or letters
- Will provider need EPCS?
- Does provider use EPCS for inpatient rounding at Covenant HealthCare?
- Does provider need EPIC training?
- Has the provider been credentialed yet?
- Providers date of birth
- Providers MI License #, date issued, and expiration date
- Providers NPI
- Providers DEA
- Providers MICR ID
- Providers Quest ID
- Will provider attest to Meaningful Use or has done so previously?
- How should MyChart message pools be setup or is there another provider to mirror?
- Providers schedule?
- If adding new staff, please provide name of employee(s), their date of birth, and job function?
- Affiliate Technical Contact Information