KARS External Request Form

Last Name *

First Name *

Middle Initial

Title *

Email *

Mobile Phone Number *

Last 4 of SSN/PIN *

Organization *

Is user a past contractor? * Yes No

Approver at Organization *

Organization Approver's Title *

Organization Approver's Email Address *

Organization Approver's Phone Number *

Type of Staff Billing Service Staff Insurance Verifier Physician Staff EPIC TS Other

Business Justification Eligibility Status Claims Status Referral Status/Entry Remittance Advice Report Order Entry Other

PreviousPlanLinkUserField Yes No If yes, please provide your previous user ID

TIN *

Comments

eSign Yes