Provider Request Sheet

UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY

PHYSICIAN INFORMATION SYSTEMS

Scheduling Provider Request Sheet

Select Activity: (Blank)AddEditRemove HEAT TICKET#:

Full Name:

(Blank)DOMDPHDPANPMSNPSYDMARNDPMCNMCNSAPNLCSWLSW
Last Name / Title / First Name / MI

For Edits Only:

Numeric Code: Mnemonic:

Scheduling Dept(s): [SD301]

Pre-Scheduling Message:

Post-Scheduling Message:

Corresponding Billing Provider(s): (from Existing Billing Providers) [BD3] Complete only for Physician Extenders and Residents.

Provider Category (Sched):(Blank)Family MedicineInternal MedicineGeriatric MedicinePediatricsGeneral SurgeryObstetrics & GynecologyGastroenterologyOsteosciencesPulmonaryCenter for Childrens SupportVascular SurgerySports MedicineDevelopmental DisabilitiesHeadache CenterPhysical MedicineEndocrinology Reporting Credentials: BlankAttendingMidwifeNursePsychologistResidentSocial WorkerTechnicianOther

Default Location(s): (This field should be left blank for multiple locations) [SD331]

Non-Billing Provider?: NY (This must be answered NO if this provider is to appear on the Missing Charge Report)

Phonetic Spelling for Televox: Is this a PCP?: NY

Corresponding Billing Location for Sched: (This field should be left blank for multiple locations) [BD100]

Corresponding Billing Area: [BD202]

Visit Types * If this is a new visit type for the Department, please complete the Scheduling Department/Visit Type Request form

Primary Scheduling Department to copy associated Visit Types: Copy ALL Visit Types:

Ø  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Visit Type:
Duration:

Secondary Scheduling Department to copy associated Visit Types (if applicable): Copy ALL Visit Types:

Ø  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Visit Type:
Duration:

Additional Scheduling Department to copy associated Visit Types (if applicable): Copy ALL Visit Types:

Ø  Complete the boxes below ONLY if duration of visit types differ for this provider from the Department standard

Visit Type:
Duration:

Use Televox Existing Department Script: YN If existing department script is not to be used, complete and submit the Miscellaneous Form along with a copy of the new/revised script.

COMMENT SECTION:

Administrator: Date:

REMINDER: A BILLING PROVIDER FORM MUST ACCOMPANY THIS FORM IF NEW PROVIDER IS BEING ADDED

Revised 3/8/07