Northlake Campus
600 Grant Street
Gary, Indiana 46402
Midlake Campus
2269 West 25th Avenue
Gary, Indiana 46404
Southlake Campus
8701 Broadway
Merrillville, Indiana 46410
Welcome to the Methodist Login Request Form. Please fill all required fields, once complete click "View Form to Print" at the bottom to print the printable form. Please print, sign and fax to (219) 795-8896.
* Required fields are in blue
Requester's Info:
First:
Middle:
Last:
Job Title:
Business Email:
Security Code:
Last 4 digit of SSN
Date of Birth
(mm/dd/yyyy)
Office Info:
Company/Office Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Phone Number:
Manager's Info:
First Name:
Last Name:
Business Email:
Phone Number:
For Billing Services Only:
Are you a billing service?:
Yes
No
If yes please enter name(s) of Physician you bill for:
Doctor(s) Name:
Example 1: (Dr. Smith, Dr. Doe, ...)
Example 2: (Doctors Group Name)
Note: Your request will take 2 weeks to process.
If you have any questions or need assistance with this form or process, please call
(219) 886-5000. Thank you.