Individual Provider Enrollment (Authorized Representatives) Page

You use the Authorized Representatives page when enrolling as an individual provider to add or edit information about a group or institution provider’s authorized representatives. Authorized representatives are individuals that may make decisions on behalf of the provider practice. Authorized representatives can also be added for individual providers, though they are not required.

The Authorized Representatives page for Individual Provider Enrollment contains the following pod and panels:

Authorized Representatives
Pharmacist in Charge

Authorized Representatives Fields

Field Name	Description
To add an authorized representative, click Add Authorized Representatives. Existing representative information, if any, is listed in a table. To edit, in the Authorized Representatives table, click the appropriate row. After changing or adding new information, on the Authorized Representative action bar, click Save.
Last Name	The authorized representative's last name.
First Name	The authorized representative's first name.
MI or Middle Initial	The authorized representative's middle initial.
Suffix	The authorized representative's suffix.
Title	The authorized representative's title.
Begin Date	Authorized representative's beginning date.
End Date	Authorized representative's ending date.
Date of Birth	The authorized representative's birth date.
Position	The authorized representative's position in the organization.

Pharmacist in Charge Fields

Field Name	Description
Last Name	The pharmacist's last name.
First Name	The pharmacist's first name.
Middle Initial	The pharmacist's middle initial.
Title	The pharmacist's title.

Version as of 5/16/14.