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EMEDNY PTAR/MMTP FACILITY ADMINISTRATOR USER ID REQUEST FORM NEW/EXISTING PTAR USER INFORMATION Name First Last Phone E-mail Address PTAR FACILITY INFORMATION Facility Name Facility Address City State ZIP Code 8-Digit NYS MMIS Provider ID REQUESTING PTAR FACILITY ADMINISTRATOR INFORMATION Facility Administrator First Your PTAR User ID E-mail PTAR ADMINISTRATOR ID ACCESS REQUEST OR CHANGE Is this request for A New PTAR Administrator ID An Existing PTAR Administrator ID If Existing what is the...
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