|PROMED HEALTHCARE FTP REQUEST FORM
out this form to generate a faxable document (
on the Generate Fax button at the bottom of the page
the generated document (when printing use
"Landscape" mode for better result)
HIPAA compliance have your contracted provider/group read the fine
prints and sign the document
the document to the number on the generated fax document
the provider/group information in the fields below. All
"*" are required.
If a field is not applicable please use "N/A"
in the field.