Epic Referring Provider (SER) Record Request Form

Use this form to submit a request to create or update an Epic Provider Record (SER) for mid-level (NP, PA) providers and physicians. By using this form, the request will be automatically be assigned to Epic Security.

Please allow up to 3 business days for this request to be completed.

DO NOT include any Protected Health Information (PHI) on this form.

Requestor's first name: *

Requestor's last name: *

Request type: *

Provider's full name: *

Provider's title (MD, PA, NP, etc.): *

Provider's gender: *

Provider's gender:

Provider's specialty: *

Provider's specialty:

Provider's street address: *

Provider's street address:

Provider's city: *

Provider's city:

Provider's state: *

Provider's state:

Provider's zip code: *

Provider's zip code:

Provider's phone number: *

Provider's phone number:

Provider's fax number: *

Provider's fax number:

Provider's NPI number: *

Provider's NPI number:

Comments or special requests (add interface ID, update SER 9300 items 89, 90, etc.):

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