Information for Providers

Send Information about a New Provider

Use the form below to submit information about a new provider who is not currently in the Lifespan system. Form results will be sent to the Lifespan Medical Staff Office.

I am submitting this form:

Your Information

Name of person submitting form

Provider Information

Provider Name

Primary Practice Address

Street Address
Type of EHR Used
Would you like to add a second address?

Second Practice Address

Second Location Information

Second Location Address
Type of EHR Used at Second Location

Additional Comments