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Facility Email Change Request Health Claims for Auto Insurance Processing 2235 Sheppard Avenue East, Atria II. Suite 600 Toronto, Ontario M2J 5B5 [email protected] Fax.: 416 497 6505
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240 Duncan Mill Road, Suite 800, Toronto, Ontario, Canada M3B 1Z4 Tel.: (416) 445-5912 Fax.: (416) 445-8383 |
Read this BEFORE you submit this form. This form is required if the following conditions apply:
No user in the practice has access to the Facility Administration tab in HCAI (shown below)
As long as there is a user administrator in the practice who can access the Facility Administration tab (shown below) the Authorizing Officer’s email can be changed internally.
The Authorizing Officer’s email address is incorrect; therefore password reset emails are not arriving to the Authorizing Officer
Please follow these instructions:
If you are completing the form by hand, PRINT clearly and complete all information in full.
Return the completed form by courier or FAX 416-497 6505, attn: HCAI Processing.
Existing Information ( * = mandatory field)
*Facility Name (as registered)
HCAI Facility Number (if available)
*Address:
*Name of Authorizing Officer
*Old Email Address:
New Authorizing Officer Email Information
*Correct/new Email Address
Is password reset for AO required? _____Yes _____No
Owner/Authorizing Officer (AO) Information
Name:
Phone:
AO Signature: ___________________________________
Date:
(NAME OF FACILITY) C HILD CARE EMERGENCY BASIC EMERGENCY
(NAME OF FACILITY) C HILD CARE EMERGENCY CHECKLISTS DATE
0510 SECTION 22 12 16 FACILITY ELEVATED POTABLEWATER STORAGE
Tags: change request, change, request, claims, insurance, email, facility, health