ProMed Health Care
Online Request Form for PVMG / UMG / CALNET / CITRUS		  
INSTRUCTIONS
  1. Fill out this form to generate a faxable document ( document example).
  2. Click on the Generate Fax button at the bottom of the page
  3. Print the generated document (when printing use "Landscape" mode for better result)
  4. For HIPAA compliance have your contracted provider/group read the fine prints and sign the document
  5. Fax the document to the number on the generated fax document
PROVIDER INFORMATION
Enter the provider/group information in the fields below. All fields with "*" are required. If a field is not applicable please use "N/A" in the field.
IPA : *
PROVIDER / GROUP :
 *
TAX ID : *
ADDRESS :
 *
CITY : 
 *
STATE: * ZIP: *
PHONE :
* FAX : *
CONTACT NAME :
 *
CONTACT EMAIL : *
ACCESS LEVELS LEGEND
1 SEARCH AND VIEW ELIGIBILITY
2 SEARCH AND VIEW AUTHS
3 SEARCH AND VIEW CLAIMS
4 SUBMIT AUTHORIZATIONS
Combine levels for custom access. For example to give a user access to view authorizations and view claims you have to check #3 and #2.

USER INFORMATION 
Enter your staff information below and select their access level (see legend above for explanation), we will create an account for each user and contact you to give you their login and password. All fields with "*" are required. If a field is not applicable please use "N/A" in the field.
  FIRST NAME * LAST NAME * ACCESS LEVELS * (See legend) TITLE * EMAIL * PHONE * FAX *
1
1- 2- 3- 4
2
1- 2- 3- 4
3
1- 2- 3- 4
4
1- 2- 3- 4
5
1- 2- 3- 4
6
1- 2- 3- 4
7
1- 2- 3- 4
8
1- 2- 3- 4
9
1- 2- 3- 4
CLICK GENERATE FAX ONLY ONCE! (Duplicate submissions might result in delaying your request)