• Provider Portal Access Request

  • The Provider Portal Access Request process ensures secure and compliant access to the updated online provider portal. All individuals seeking access must complete a Confidentiality Agreement, regardless of any prior agreement or signatures.

  • What type of account are you requesting?*

  • Please provide the facility or physician email to access the Portal.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • To ensure appropriate access to patient information, are there any providers in your office who already have access to the MedQuest Portal whose patients you will also need to access?*
  • Rows
  • Are there any providers or staff members in your office whowill require access to the MedQuest Portal?*
    • Provider #1 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Provider #2 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Provider #3 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Provider #4 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Provider #5 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Staff Member #1 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Staff Member #2 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Staff Member #3 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Staff Member #4 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Staff Member #5 (Drop Down) 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Location Address*
    • Acknowledgements 

    • Access Requirements
      To request access to the provider portal, every applicant is required to complete the Confidentiality Agreement. This requirement applies to all users, even if they have previously signed similar agreements. The agreement is an essential step to maintain the privacy and security of sensitive patient information.

      User Obligations
      By signing the access request, users acknowledge and agree to follow in accordance with HIPAA regulations and the requirements for Protected Health Information (PHI). This includes access to patient images, reports, and the ability to order exams. Users must understand that access is granted exclusively for authorized users.

      Effective Date
      The agreement becomes effective on the date it is signed by the user.

      Signature Requirement
      A single signature is required to complete this request. It is preferred that the signature comes from an office manager, supervisor, or senior representative of the requesting entity.

      Authorization and Acknowledgement
      By utilizing the online portal, the undersigned certifies and agrees to the requirements. This request allows access to the provider portal and affirms that any orders initiated and submitted using this account will be deemed to have been submitted and authorized by the user. The undersigned agrees that all orders placed with their user ID (email) will represent that they are the treating physician or practitioner for the patient. Furthermore, each order submitted by the user will be electronically signed in the user’s name.

    • Signature Requirement
      A single signature is required to complete this request. It is preferred that the signature comes from an office manager, supervisor, or senior representative of the requesting entity.

    • Clear

    • By submitting I understand this is a legal representation of my signature.

  • Date and Time of Request
     / /
  • Should be Empty: