City: State: Zip:
Does your practice use an EMR?
If Yes, what is the name of your practice's EMR?
If No, how do you share information with other provider offices?
Should you need to update your TIN, please fax a separate written request to Provider Relations at (650) 497-6898.
First Name: Last Name: Provider Address: City:
Telephone: Fax: Office Hours:
Form Submitted by:
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