CommuniCare 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
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
Alderson's Nursing Facility
Cache Creek High School
Cottonwood SNF
Courtyard SNF
Davis Community Clinic
Dental Davis
Dental Esparto
Dental Peterson
Dental Salud
John Jones Clinic Woodland
John Jones Clinic West Sac
OB DCC
OB Dixon
OB Peterson
OB Salud
OB Winters
Peterson Clinic
Salud Clinic
Sierra SNF
Somerset SNF
Sutter Davis Hosp
Sutter Davis Hosp - Newborn
UCD Retirement SNF
Women's Health Davis
Woodland Community College
Woodland SNF
Male
* Req'd
Female
* Req'd
FTE
* Req'd
PSAC Setting (optional):
Tax ID Details
Provider Tax ID :
* Req'd
NPI
* Req'd
Accept
Clearinghouse?
Yes
No
Visit Duration
* Req'd
State License *
Optional
Copy Visit Type Duration
from provider name
Requestor Name
Email:
* Req'd
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