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.

List the location name and Epic Department ID that has incorrect information.

If the address is incorrect, list the correct information below. Note any offices with correct information.

If the phone number is incorrect, list the correct information below. Note any offices with correct information.

If something else is incorrect, please note it below.

Use this field for locations that are correctly assigned in Epic, but are not appearing on the public provider directory. Do NOT use this form for adding new locations to a provider profile. Include the Epic Dept ID in the details below.

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.

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

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