Provider Update Request Form

Specialties are based on official Board Certifications. They can only be changed if a new certification has been achieved, lapsed, or if the listed certifications are incorrect.

The Clinical Area of Focus is meant to supplement listed Specialties. Examples include adding a focus area to a Family Nurse Practitioner who practices Cardiology, or to reflect that doctor certified in General Surgery frequently performs Breast Surgery.
- No more than three Clinical Areas of Focus.
- Conditions and treatments do not qualify for Clinical Area of Focus.

Enter the incorrect location, the correct location, and the correct order. Include the location name and Epic Department ID to ensure the correct changes are applied.

Enter the location that should be linked and the correct order. Include the location name and Epic Department ID to ensure the correct changes are applied.

Enter the location that needs to be removed. Use this option if the provider is no longer billing or scheduled to see patients at this location. Include the location name and Epic Department ID to ensure the correct changes are applied.

Is this provider covering or on call at the location you're asking to remove?

Enter the location that should not be publicly visible. The existing location(s) will be retained for billing and on call scheduling purposes. Include the location name and Epic Department ID to ensure the correct changes are applied.

Enter the locations and their correct order. Include the location name and Epic Department ID to ensure the correct changes are applied.

Provide the incorrect phone number and the correct phone number. Include the location name and Epic Department ID to ensure the correct changes are applied.