Provider Online Access Form - Memorial Hermann Health Solutions

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Individual Provider/Provider’s Office Authorized User Access Request FormSection 1 – Create new user access (Please fill out a separate form for each new user)Provider’s Name:Provider’s Office Location(s):City: State: Zip Code:Check to allow access to all Provider’s location(s):Provider’s Tax ID Number:Provider’s NPI Number:User’s First Name:User’s Last Name:User’s Job Title:User’s Date of Birth (mm/dd/yyyy) :User’s Phone #:User’s Email Address:2 | P a g e
Individual Provider/Provider’s Office Authorized User Access Request FormSection 2- Change existing user information / Terminate existing user’s accessUser ID:User Name:User’s Email:User’s Phone #:Please list below all the changes to be made to the above mentioned user’s account.For MHHSI information validation use only. Do not write in the below section.3 | P a g e
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Provider Online Access Form - Memorial Hermann Health Solutions

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