Hospital:  **

Contact Person: **

Phone Number: **

Fax Number:

EMail Address:

** Required entries

Please list below the number of the physician you are adding or deleting:

Add Physician #

Delete Physician #

For more information about adding a doctor or changing the authorization number, please refer to Section 3 - Configuration of your user manual. If you still require assistance, please contact the Helpdesk at (604) 540-4400, by fax (604) 540-4020, or e-mail us.