Behavioral Health

Enterprise Information System (EIS) - Request for Organization Data Change or Addition Form

Requestors Name:

Request for
Addition:
Change:

Service Population
MH:
MR:
Children:
MECMS:

Organization
Organization Name:
Sub Location:

Organization Mailing Address:

Phone Number:
FAX Number:

Billing Number:
EIN:

Organization Type:
Organization Specialty:
Sub Specialty:

Reviewed by regional organization data representative Date:

Authorized by SP Lead Name:
Authorized by SP Lead: Date:

Name of Regional Rep:
Security Coordinator:

People Needing Access: