Alexander Valley Healthcare 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
Clnic Fax No.
* Req'd
Resident?
Yes
No
Start Date
* Req'd
Specialty
* Req'd
ePrescribing
Yes
No
Primary Service Location
* Req'd
Select One
Alexander Valley Healthcare
Clearwater Lodge
Cloverdale Health Care Center
Male
* Req'd
Female
* Req'd
FTE
* Req'd (estimate .05 increments)
Tax ID Details
Provider Tax ID :
* Req'd
NPI
* Req'd
Accept
Clearinghouse?
Yes
No
State License * Optional
License Active Date * Optional
License Term Date * Optional
Requestor Name
Email:
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