Medical Director or Equivalent tab

Responsible Medical Provider/Medical Director tab

Purpose

This accordion tab will be displayed with a different tab header based on the organization category.

Responsible Medical Provider or Authorized Signer when organization category is TVFC = No

Medical Director or Equivalent (Responsible Medical Provider) when organization category is TVFC = Yes

Required Fields

Field Name	Description
I am an Authorized Signer for this Organization	If you are the authorized signer for this organization, check the box and the details will be prepopulated with your details. You can modify, if needed.
First Name	Required. The provider's first name.
Middle Name	The provider's middle name.
Last Name	Required. The provider's last name.
Job Title	Required. The provider's job title.
Specialty	Required. The provider's area of specialization.
License Type	Required. The license type the provider holds.
License Number	Required. The license number associated to the license type selected.
NPI Number	Required. The provider's National Provider Index number.
Provider Medicaid ID	The provider's Medicaid ID.
Employee ID Number	The provider's employee number.
Email	Required. The provider's email address.

Go to Practicing Providers with Prescribing Authority tab

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