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If your practice already uses Order Facilitator, please use this form to add or remove providers for your practice:

When changes have been processed, you will receive a confirmation email.

Office/Practice Information


Practice Address*
This helps us verify that we are updating the provider at the exact group you wish to modify
Do you need to add or remove provider(s)?*

Add Providers

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.

Provider 1*
Provider 1 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 1 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Please note any special set-up for this provider. E.g., If your practice has multiple locations and this provider practices at only one of them.
Add another provider?*
Provider 2*
Provider 2 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 2 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Please note any special set-up for this provider. E.g., If your practice has multiple locations and this provider practices at only one of them.
Add another provider?*
Provider 3*
Provider 3 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 3 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Please note any special set-up for this provider. E.g., If your practice has multiple locations and this provider practices at only one of them.
Add another provider?*
Provider 4*
Provider 4 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 4 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Please note any special set-up for this provider. E.g., If your practice has multiple locations and this provider practices at only one of them.
Add another provider?*
Provider 5*
Provider 5 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 5 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Please note any special set-up for this provider. E.g., If your practice has multiple locations and this provider practices at only one of them.
If you are adding more than 5 providers, please complete/submit an additional form*

Remove Provider 1

Remove Provider 1 Name*
Do you have another Provider to remove?*
Please note any special set-up for this physician. E.g., If your practice has multiple locations and this physician practices at only one of them.

Remove Provider 2

Remove Provider 2 Name*
Do you have another provider to remove?*
Please note any special set-up for this physician. E.g., If your practice has multiple locations and this physician practices at only one of them.

Remove Provider 3

Remove Provider 3 Name*
If you have more than 3 providers to remove, please submit another form*
Please note any special set-up for this physician. E.g., If your practice has multiple locations and this physician practices at only one of them.

Scheduling.com (SCI Solutions) Services Agreement - For Physician

Do you agree with the terms of the preceding license agreement?*
Are you sure that you DO NOT accept the terms of the agreement?*
Name:*
Representative of your practice to contact if we have questions related to this request
Use your mouse or finger to draw your signature above

Submit your information

Thank you for completing the SCI Order Faciltiator Add/Remove Provider form for {$53110178 Physician Office/Practice Name}.

If your information is complete, please press the SUBMIT button below.  If you need to add additional provider updates, 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.

 

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Save and Resume Later
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