KARS External Request Form

Last Name *

First Name *

Middle Initial

Title *

Email *

Mobile Phone Number *

Last 4 of SSN/PIN *

Organization

Is user a past contractor? * Yes No

Approver at Organization *

Organization Approver's Title

Organization Approver's Email Address

Organization Approver's Phone Number

Type of Staff Billing Service Staff Insurance Verifier Physician Staff EPIC TS Other

Business Justification

Comments

eSign Yes