Petaluma eCW Provider Request Form
Personal Info
Last Name
* Req'd
First Name
* Req'd
Middle Initial
Provider Initials
* Req'd
Degrees/Credentials
* Req'd
DEA Number
* Optional
DEA Active Date
* Optional
DEA Term Date
* Optional
Mailing Address
* Req'd
City
* Req'd
State
* Req'd
Zip Code
* Req'd
Fax No.
* Req'd
Start Date
* Req'd
Specialty
* Req'd
ePrescribing
Yes
No
Primary Service Location
* Req'd
Select Facility
PHC Dental
PHC Fam Prac
PHC Mental Health
PHC OB
Male
* Req'd
Female
* Req'd
FTE
* Req'd
(estimate .05 increments)
Tax ID Details
Provider Tax ID :
* Req'd
Accept
Clearinghouse?
Yes
No
NPI
* Req'd
Accept
ePrescribing?
Yes
No
State License
* Optional
License Active Date
* Optional
License Term Date
* Optional
Comments/Notes
Please include your name in comment box for proper authorization
.
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