Get Medco Change Of Ownership Form

Completing the Medco Change Of Ownership Form is an essential process for maintaining accurate provider information. This guide will walk you through each step, ensuring you fill out the form correctly and efficiently.

Follow the steps to complete the form accurately.

1. Click 'Get Form' button to obtain the form and open it for editing.
2. Identify the type of provider number you are updating—either an individual provider number or a business/organizational provider number. Remember that a separate form is required for each provider number update.
3. If applicable, submit the National Provider Identifier (NPI) verification alongside the form.
4. For business or organization providers, if you have a new tax identification number, complete this form and attach a new W-9 IRS form for record-keeping. Ensure to state when the former provider number became invalid and when the new number became effective. Note that no bills will be payable for services after the termination date of the previous provider number.
5. Fill in the new tax identification number or Social Security number. Attach the IRS Form W-9, as this number will be used for IRS documentation.
6. Enter the legal name associated with the tax identification number as recognized by the IRS, along with the Doing Business As (DBA) name, if applicable.
7. Select the business type, such as individual, sole proprietor, partnership, corporation, S corporation, LLC, or non-profit.
8. Provide the new owner name(s) and the updated practice location address, including any necessary suite or floor information.
9. Complete contact information fields, including telephone, fax, email address, reimbursement address, and correspondence address, if they differ from the practice location.
10. Sign and date the form. Ensure that the applicant or authorized personnel signature is included as it is a requirement for reimbursement changes.
11. Once you have filled out the form completely, you can save changes, download, print, or share the finished document as needed.

Complete the Medco Change Of Ownership Form online now to ensure your information is accurate and up-to-date.