Centricity Business Referring Provider Request Form
REQUESTOR
Select Activity:
Add
Service Request (SR) #:
Full Name:
(Blank)
Title
Last Name
Numeric Code (Edits Only):
First Name
MI
Mnemonic:
Clinical Office Location
First Line of Address:
Second Line of Address:
City:
Phone Number:
State:
Zip:
SOM Faculty?: (Req)
ALL ARE REQUIRED TO ENTER:
UPIN:*
www.ecare.com or
www.hmedata.com
NJMA Provider Number**:
NPI #:
Tax ID:
License Number:
* Surrogate UPINs are intended to be used during an interim period when a UPIN has been requested but has not yet been received. If OTH000 is used
and a valid UPIN is not received within 3 months the provider will be deactivated.
** If NJMA Provider number has not been obtained, use the default of 5555555 for a NJ provider or 6666666 for an out-of-state provider
Submitted by:
Date:
Comment Section:
MANAGED CARE PORTION OF FORM
Excluded from Federal Programs: (Req)
Comment:
Authorized by:
Date:
IRT PORTION OF FORM
Referring Provider (BD 123)
Open Referral Ext. Provider (BD 471)
IRT NOTE: If entering a facility into Dictionary 471, an asterisk (*) must precede the facility name
Revised: 03/31/14