St. Joseph Network Support Services

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IMPORTANT!

Before you register, please read carefully. SJHH Network Support Services requires a designated "Provider On-line Account Manager" assigned by your office. This individual will be responsible for setting up new user accounts and will be responsible for maintaining the account up to date.

All fields are required if applicable, with the exception of fax number. Tax ID must contain 9 numeric characters (with or without dashes) and zip code must consist of 5 numeric characters. Before you submit your registration request, please review the information and make sure you have provided us with the latest information.

Your registration request is subject to review. We will process your registration request as soon as possible and get back to you within three business days. We are committed to providing you with excellent service.

Information About You

First Name:		Last Name:
Desired User Name:		Email Address:
Direct Phone:

Information About Provider

Provider/Group Name:		Tax ID*:
Office Phone:		Office Fax:
Office Address:
City/State/Zip Code:

Information About Billing Company (If Applicable)

Is this a billing company? Yes No
Billing Company Name:
Office Phone:		Office Fax:
Office Address:
City/State/Zip Code:

*Additional Tax IDs may be requested after user registration is complete.

Please grant me access to claim information. I understand that this function is subject to monitoring and review by St. Joseph Health System and/or designated representatives for regulatory compliance. I acknowledge that the patient data accessed is to be used solely for treatment, payment or health care operations of a particular patient. It will be my responsibility to use it in accordance with the confidentiality statement I have signed with SJHH that has granted me access. I understand any misuse or violation of Policy & Procedure will result in the loss of access for my designated staff and myself.

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