I want to change my Legal Authority (PCA)

Change Request

Administrator (PAA) and/or Legal Authority (PCA)

I want to change my Administrator (PAA)

I'm replacing with a new administrator I'm modifying my current administrator's information

?

Administrator (PAA)

Primary Access Administrator is the person who controls access to the Availity account on a day-to-day basis.

Administrator's Availity User ID Administrator's First Name

Administrator's Last Name

(If an existing Availity user)

Administrator's E-mail Address

(E-mail address should be unique to the user and not associated with any other user ID)

Administrator's Phone Number

I want to change my Legal Authority (PCA)

I'm replacing with a new legal authority

(The new legal authority (PCA) must sign this form)

I'm modifying my current legal authority's information

?

Legal Authority (PCA)

Primary Controlling Authority is usually a doctor or office manager who is entrusted to sign legal documents for your organization.

Legal Authority's First Name

Legal Authority's Last Name

Legal Authority's E-mail Address

(E-mail address should be unique to the user and not associated with any other user ID)

Legal Authority's Phone Number

This section is REQUIRED to process your request

Organization Name (1 form only per organization)

Customer ID

?

Your organization name and customer ID can be found

in "Who controls my access?" on the Availity portal.

I, the undersigned Legal Authority (PCA), do hereby attest to the accuracy and completeness of the information provided by the organization in this document and attest that I have the authority to, and hereby do, make these changes on behalf of the organization.

Printed Name of Legal Authority (PCA)

Signature of Legal Authority (PCA)

Date

Return to Availity:

Scan and Email to: 4780@

OR

Fax 904-470-2187

(Availity Security)

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