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MVP Provider Site Administrator Form
E-mail completed form to esupport@mvphealthcare.com
When to use this form:
Identify / authorize a Site Administrator or update / change the Site Administrator authorized to
request / modify / remove access the MVP Health Care Provider Web Portal.
Instructions:
All authorization requests must be communicated through use of this form.
The name of the person authorizing changes to site administrators cannot be the same
as the name of the person being added as a site administrator.
All additions, changes, and deletions must be communicated through use of this form and
MVP will only share protected health information (PHI) through its Web site with the
individual(s) listed on this form. The Site Administrator and sub-user information provided on
this form and will limit access to our Web site only to the individuals listed below.
Facility/Practice Name*:
Tax ID*:
Address:
City: State: Zip:
Current Site Administrator’s/Provider’s Name*:
Current Site Administrator’s/Provider’s E-mail*: Telephone Number*:
ADD SITE ADMINISTRATOR
Administrator’s First and Last Name*:
Administrator’s E-mail*: Administrator’s Telephone Number:
REMOVE SITE ADMINISTRATOR
Administrator’s First and Last Name*:
Administrator’s E-mail*: Administrator’s Telephone Number:
Authorization:
The name typed above acknowledges and authorizes the addition or removal of a site administrator
for the facility/practice.
* Indicates Required Field
Please contact eSupport at 1-888-656-5695 with questions about this form or MVP Web site access.
Updated 11/01/2010