ProviderMatch Admin (PMA)
Account Access Request Form
Thank you for helping to ensure that accurate information is available on BannerHealth.com provider profiles.
Please note you need to fill out all fields that may apply.
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Request Type
New User
Modify User
Delete User
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Role
Select:
Managed Data
Marketing
Executive Director
Practice Manager
Provider
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First Name
*
Last Name
*
Email
Can't find your Practice Group? Enter below:
Mention your Provider's Name as well.