Adding/Removing a Provider on Anytime.com

Adding/Removing a Provider on Anytime.com

This marketing form starts the process of adding a new provider to Anytime.com with a bio and photo. After you complete this marketing form, work with your practice manager to complete the Physician Services form to add the provider’s Athena schedule: https://app.smartsheet.com/b/form/f4c44b3a8c8d442aa0635d731fc8803b

Today's Date*

HMD Name*

Hospital Name*

Are you adding or removing a provider?*

Select

Please enter in the Provider's Name*

First and last name should be enterd here.

Removal Date

Suffix

Date the provider is onboarding on

Credentials

ex. MD, APN, etc.

NPI*

Specialty *

Credentialed Specialty*

EX Internal Medicine

Provider Gender*

Select

Languages

e.g. English

Photo Of Provider*

From a patient's standpoint, uploading a photo of the provider is important.

Drag and drop files here or

Provider Bio*

You may use the same bio from the practice site

Provider Type

Physician, Physician Assistant, etc.

Education*

Provide the medical, residency, fellowship, internship, etc

Certification

Board Certification; EXAMPLE: American Board of Surgery

Practice Location 1*

Practice Location 2

Insurance Accepted*

Please list out the insurance names ex: BCBS, United Health Care, etc. Please get in touch with the clinic or practice manager to know which insurance the provider is credentialed with.

Send me a copy of my responses

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