Practice Change Form

Name

Email

Clinic Name

Please select your type of request:

Change Practice Contact Information

Practices Primary PITO Contact Name

Clinic Name

Address Line 1

Address Line 2

Province

Postal Code

Phone

FAX

Practices Primary PITO Contact Email

Physician leaving a group Practice with PITO funding

Physician Name

Physician MSP Billing

Physician Email

Current Practice Name

Does new Practice currently have PITO funded EMR?

Yes

No

Date

Physician leaving a PITO funded group Practice and starting a new Practice requiring a new EMR implementation

Physician Name

Physician MSP Billing

Physician Email

Current Practice Name

New Practice Name

Date

Physician entering an already PITO-funded group Practice

Physician Name

Physician MSP Billing

Physician Email

Practice Name

Date

Physician taking an extended leave from practice without a temporary replacement

Physician Name

Physician MSP Billing

Physician Email

Practice Name

Date

Approx. Length of Leave

Monthly EMR Fee Adjustment

Physician Name

Physician MSP Billing

Physician Email

Practice Name

EMR Vendor

New Monthly Amount

Details of Request