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.
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 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.