Start sending online orders and referrals now:
Please complete the enrollment form and your login credentials will be sent once your application has been processed.
Please enter information for staff members who will send and track orders and referrals.
Please enter information for physicians who create orders.
In an electronic environment, the same legal weight associated with an original signature on a paper document can be associated with an electronic signature. Physicians are not required to be employees of the participating hospitals and thus agree to allow the use of his/her signature only for the purpose of ordering procedures at the hospitals and sending referrals to other medical providers.
- I certify that the identifiers assigned to me for the purpose of this attestation process will be kept confidential, will not be disclosed to others and will be used appropriately.
- I also understand that I am ultimately responsible for any orders transmitted using Order Facilitator on my behalf by my office staff.
- Furthermore, I understand that the privilege to use the Order Facilitator system may be revoked if it is not used appropriately.
Thank you for providing information on the New Practice Enrollment to Join our Order Facilitator Community for {$53107042 Physician Office/Practice Name}.
If your information is complete, please press the SUBMIT button below. If you need to add additional users and/or providers, please use the PREVIOUS button below to make your changes. *Please note if using the SAVE AND RESUME LATER feature on this form, only typed information will be saved. Any signatures on the form will need to be resigned.
Thank you! Please remember to click the SUBMIT button below when you're finished.