ScreenWise Provider Contact Information

Question Title

* 1. Clinic Site Contact Information

Health System Name

Clinic Site Name (If Different)

Clinic Site Address (physical location)

City

State

Zip Code

County

Phone Number (for patient appointments)

Fax Number

Website

Hours of Operation

Question Title

* 2. Primary Data Collection Contact and/or ScreenWise Site Coordinator

Name

Title

Phone Number & Ext

Fax Number

Email Address

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* 3. Primary Billing Contact for ScreenWise Program. (Person responsible for claims submissions to the ScreenWise program, assist with billing issues. They will also receive monthly Explanation of Benefits (EOB) reports.)

Name

Title

Phone Number & Ext.

Fax Number

Email Address

Question Title

* 4. Additional Information To Update: