Epic Billing and/or Referral Place of Service Record Creation/Update Form

Use this form to submit a request to create or update an Epic Billing and/or Referral Place of Service Record (EAF). Submission of this form will automatically create an IS Service Request and be routed to the proper IS resources.

Your request will be completed within two weeks of receipt.

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

Requestor's name: *

Request type: *

Place of Service name: *

Place of Service: *

Place of Service:

Place of Service Type: *

Place of Service Type:

Street address: *

Street address:

City: *

City:

State: *

State:

Zip Code (9-digits required for billing): *

Zip Code (9-digits required for billing):

Phone number: *

Phone number:

Fax number: *

Fax number:

NPI number:

Comments or special requests: