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-323850160655ADVENTHEALTH SECURITY REQUEST FOR PAYER ACCESS0ADVENTHEALTH SECURITY REQUEST FOR PAYER ACCESSPLEASE INDICATE TYPE OF REQUEST:NEW USER FACILITY ACCESS CHANGE TERMINATE TERMINATION DATE: _______________PAYER USER INFORMATION (all fields must be completed):LAST NAME FIRST NAME MIDDLE INITIALPHONE NUMBEREMAIL ADDRESSDOBRN / MD LICENSE #SOCIAL SECURITY #JOB TITLE START DATE POSITION REQUESTED 3RD PARTY PAYER PAYER INFORMATION: PAYER/COMPANY/STATE*USER GROUP PLEASE INDICATE AHS FACILITIES FOR WHICH THE USER REQUIRES ACCESS: ETZAdventHealth CarrollwoodETZAdventHealth WauchulaETZAdventHealth Connerton (LTAC)ETZ AdventHealth Wesley Chapel ETZAdventHealth Dade City ETZ AdventHealth Zephyrhills ETZAdventHealth Daytona Beach ETZAdventHealth Gordon ETZAdventHealth DelandETZAdventHealth Manchester ETZAdventHealth Fish MemorialETZAdventHealth Murray ETZAdventHealth Lake PlacidETZAdventHealth HendersonvilleETZAdventHealth New Smyrna BeachCTZ Texas Health HuguleyETZAdventHealth North PinellasCTZAdventHealth Rollins Brook ETZAdventHealth Ocala CTZAdventHealth Central Texas ETZAdventHealth Palm Coast CTZCentral Texas Medical CenterETZ AdventHealth Sebring CTZAdventHealth Durand (CVH)ETZ AdventHealth TampaCTZAdventHealth Shawnee MissionETZAdventHealth Waterman-36195028575000AUTHORIZED PAYER ACCESS LIAISON SIGNATURE: _____________________________________ Date: ______________*OPID: _____________ *COST CENTER: _______________*To be completed by AdventHealth ................
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