You must complete all required fields on the form as indicated in red

MVP Provider Web Site Access Form

When to use this form: Please use this form to request, modify or remove online access for individual users acting on behalf of named provider entity.

Instructions: All user site access requests must be communicated through use of this form. All fields in sections 1 and 2 must be completed to properly process the request. Tax ID is required to process requests. Requests without a valid Tax ID cannot be processed.

The Provider Site Administrator is responsible to notify MVP Health Care eSupport when users with access no longer require access (e.g. leave, are no longer with provider/no longer affiliated, Billing Group relationship changes, etc.)

All additions, changes and deletions must be communicated through use of this form and MVP will only share protected health information (PHI) through its Web site with the individuals listed on this form. The Site Administrator and sub user information provided on this form will limit access to our Web site only to the individuals listed below.

Please contact eSupport at 1-888-656-5695 for questions concerning this form or MVP Web site access.

1. Site Administrator Information: Complete this section for all requests.

Facility/Practice Name Facility/Practice Name is required and accepts only characters
Address Address is required and accepts only AlphaNumeric
City City is required and accepts only characters State Zip Code Zip is required and must be in xxxxx or xxxxx-xxxx format (ex. 12345 or 12345-0001)
Tax ID Tax ID is required and must be in xxxxxxxxx format (ex.123450001)
First Name First Name is required and accepts only characters Last Name Last Name is required and accepts only characters
Email Email is required and must be in xxx@xx.com format (ex.test@mvp.com)
Phone Phone must be in xxx-xxx-xxxx format (ex.123-456-7890) Ext.

User Designee Information: Complete this portion to add, change and delete other MVP Web site users in your facility / practice now and on an ongoing basis. The Site Administrator shown above hereby authorizes MVP to grant Web site access to protected health information (PHI) to the individuals designated below:

Please select the appropriate box (Add, Change or Delete) for each individual listed below:

2. Site Users: Complete this authorization request for all users in your office.

User's First Name User First Name is required and accepts only characters Last Name User Last Name is required and accepts only characters
User's Email Address Email is required and must be in xxx@xx.com format (ex.test@mvp.com)
User's Phone Phone must be in xxx-xxx-xxxx format (ex.123-456-7890) Ext.