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NYC Health+Hospitals Advantage Access Request Form - NYC Health+Hospitals Employed Providers Only
You must be an NYC Health+Hospitals-employed physician or other clinical provider to request system access using this form.  If you are not a provider but are an HHC staff member, please use the regular NYC Health+Hospitals Advantage Access Request form.  If you are a provider and also require NYC Health+Hospitals Advantage system access to refer patients to an NYC Health+Hospitals facility or a NYC Health+Hospitals Advantage Community-Based Organization from your outside practice, you must notify your facility‚Äôs NYC Health+Hospitals Advantage Administrator or Provider Relations Manager separately, and will be issued a separate account.  You cannot use your NYC Health+Hospitals-employee provider's account to refer patients from your outside practice.
Title:  
First Name:  MI:  Last Name:
Suffix:
I am a (Job Title) Provider Subtype:
Primary Specialty: Secondary Specialty:
Primary NYC Health+Hospitals Facility: Clinical Service Area:

Terminal Degree:
NYS License No.:    Help  - NPI:
Phone 1:  Ext.:  Phone 2:  Ext.:  
Provider Emergency Phone No.:  Ext.:  Fax:
NYC Health+Hospitals Email Address: Confirm Email Address:
Please state your reason for requesting system access (300 characters max):
Do you require access to the Patient Transfer module?

LDAP User Name:  
Your LDAP user name is the same user name you use to access NYC Health+Hospitals email and the Internet.

LDAP Password:
Your LDAP password is the same password you use to access NYC Health+Hospitals email and the Internet.
It is used for verification purposes only and will not be sent to the NYC Health+Hospitals Advantage system administrator.