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 Request Form

 
For questions about this form, please call 415.972.4350 or email physicianservices@btmg.com
If you already have a user name and are locked out of your account, please contact our IT Service Desk at ph. 415.972.6008 for account re-enablement.
I am requesting BT/ABMG CARE access and I work for the following:
*Please choose one option from below
*Please choose one option from below




Personal Information

*First Name:
Middle Name:
*Last Name:
Title of Position:
*Direct Phone Number:
*Your Email:

Contact Office Information

*Do you have an existing BT/ABMG CARE account?

 
Does your company have a direct contract with Brown and Toland Physicians?

Does your company have a direct contract with the health plans?

*Please select the health plan(s) for which your are contracted.












*Primary Office Address:
Office Name:

*Primary Office Phone Number:
ext:  
Primary Office Fax Number:
 

*Office Manager Name:
*Office Manager Phone:
ext:  
 

Practice Information

*Practice Name:
*TIN: ex:(XXXXXXXXX)


 
List all providers with TIN
*Provider :
*TIN : ex:(XXXXXXXXX)
 
Add

Remove

Require Clinical Results Reporting?

Clinical Results Reporting (CRR), provides access to review laboratory and dictated reports, as well as reviewing radiology results for patients. Clinical results are available for services performed by our hospitals and laboratory partners.
If you require access to Clinical Results Reporting please fill out the CRR request form .
You can email the signed form to physicianservices@btmg.com or fax back to 415.972.4189.

DISCLAIMER

I understand that information contained on the Brown & Toland’s BT/ABMG C.A.R.E. is protected and confidential and intended only for the use of Brown & Toland contracted providers and their authorized office staff. I agree to educate my staff on the appropriate use and confidentiality of the Brown & Toland BT/ABMG C.A.R.E. information. I agree to notify Brown & Toland in writing of any changes to the above staff list. I understand that any unauthorized access, distribution, or copying of information contained on the website is strictly prohibited and subject to Brown & Toland pursuing appropriate action, which could range from restricted access to legal sanctions.
I agree:  
Please allow 7-10 business days for request access.