Is THE SOURCE for information on your patients who …

New Office RNeewquOeffsicteFReoqrumest Form

Form provided by: _A_l_e_xa_n_d_r_a_(_L_o_u_)_S_t_e_v_e_n_so_n_____________ Date: _____________________________________________

Office Information

Name: Address:

City:

State:

Zip:

Phone: ( )

Fax:

Practice NPI:

Site Admin Info

First Name: SSN (last 4 digits): Job Title: Primary Phone: ( )

Last Name: DOB: Birth City: Primary Email:

Middle Initial:

Provider Info

First Name: Provider NPI: License Number:

Last Name: Specialty:

Middle Initial:

First Name: Provider NPI: License Number:

For morLeasitnNfaomrem: ation, or to schMeidddulelIenitaianl: appoSipnetcmialtey:nt for your patient, call

(813) 844-5480.

First Name: Provider NPI: License Number:

Last Name: Specialty:

Middle Initial:

First Name: Provider NPI: License Number:

Last Name: Specialty:

Middle Initial:

First Name: Provider NPI: License Number:

Last Name: Specialty:

Middle Initial:

By clicking "submit," Adobe will attempt to open your email client and send the completed form to the TGH EpicLink email address. If this doesn't work, please click the "save" button to save a copy of the form.

Email the form to PhysicianRelations@ or fax it to (813) 844-4673. Submit

FORM #: E379, 10/20

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