VIVA HEALTH Provider Information Form
Viva Health is in the process of replacing EPOWER with a new provider portal. Please confirm your information by completing this form.
Email address
Are you requesting patient information as a third party administrator (TPA) or billing office outside of the actual provider's office?
1. Admin user's first and last name:
Your answer
2. What username would you like to be assigned?
Your answer
3. Admin user's email address:
Your answer
4. If there are multiple physicians in the same office, please list their names and NPI#:
Your answer
5. NPI & Tax ID# associated with this provider:
Your answer
6. Physical address:
Your answer
7. List the name and address of any physician listed in question #4 that is currently seeing patients at a different address than was indicated in question #6:
Your answer
Please complete the captcha before submitting the form.
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