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