EMR Regional Provider

Physician Name*
First Last
Physician Facility*
National Provider Identifier Number (NPI)*
Texas Medical License Number*
Primary Email
Primary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Office Phone
Primary Fax
UPLOAD - Facility Template Information Access and Confidentiality Agreement
Accepted file types: pdf.
Please Attach the scanned copy of the signed “Information Access and Confidentiality Agreement”
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