Health care provider contact information

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Provider Change Form

If you are a community provider and would like to receive your patient’s medical records electronically through Health Report Manager (HRM), or if you have recently moved or have new contact information, please complete the below form. This will ensure your provider record at Mackenzie Health is up to date to ensure the timely transition of medical records.

To submit any changes to your provider record, please complete the following form. Fields marked with * are mandatory.

First name: *

Last name: *

CPSO #: *

Clinic or practice name:

Address: *

No change in addressAdd as an additional addressMoved, remove previous location

Phone number: *

Fax number: *

Preferred routing method:

Health Report Manager (HRM)Fax

For retiring providers, please indicate the effective date of your change in status: