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

MVP Provider Site Administrator Form

When to use this form: Authorize a Site Administrator or update / change the Site Administrator authorized to request / modify / remove access to the MVP Health Care Provider Web Portal.

Instructions: All authorization requests must be communicated through use of this form. The name of the person authorizing changes to Site Administrators (The Supervisor) cannot be the same as the name of the person being added as a Site Administrator.

All additions, changes, and deletions must be communicated through use of this form. MVP will only share protected health information (PHI) through its Web site with the individuals.

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

1. Supervisor 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.

2. Web site Administrators: Complete this section for all requests.

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