Complainant (Provider)

This screen allows users to enter information about a provider. The first time this screen loads, it will display the Provider Search popup. If a user searches for and selects a provider, the information will automatically be populated in read-only mode on this screen. Users may also choose to continue without selecting a provider by closing the Provider Search popup. When this occurs, users will need to enter basic information for the provider.

 

Field Name

Field Description

Select Provider/Location

Click the Select Provider/Location hyperlink to reopen the Provider Search popup and select a new provider or service location.

MPI Number:

This is a read-only field that displays the provider's Master Provider Index (MPI) number.

Provider Name:

This field displays the name of the provider associated to the MPI.

Service Location ID:

This field displays the provider's four-digit Service Location ID that corresponds to the site address where the service is contracted with the county.

Service Location Name:

This field displays the provider's service location name.

Phone:

This field displays the provider's phone number.

Email:

This field displays the provider's e-mail address.

Address Line 1:

This field displays the provider's street address.

Address Line 2:

This field displays the second line of the provider's address, if applicable.

Address Line 3:

This field displays the third line of the provider's address, if applicable.

City:

This field displays the city corresponding to the above address.

County:

This field displays the county corresponding to the above address.

State:

This field displays the state corresponding to the above address.

Zip code:

This field displays the zip code corresponding to the above address.

Staff First Name:

Enter the first name of the staff member.

Staff Last Name:

Enter the last name of the staff member.

Provider Type:

Select the provider’s Provider Type.