Get Amerihealth Change Providers Form

Filling out the Amerihealth Change Providers Form is essential for updating your practice or physician information with Amerihealth. This guide provides you with clear and systematic instructions to complete the form online with ease.

Follow the steps to fill out the Amerihealth Change Providers Form effectively.

1. Click ‘Get Form’ button to obtain the Amerihealth Change Providers Form and open it in your preferred editor.
2. Indicate whether the change affects a group practice or an individual physician by selecting the appropriate option.
3. Provide the name and NPI (National Provider Identifier) effective date for the group practice or individual physician.
4. Input the Group Practice or Individual Physician provider number, along with the HMO and PPO ID numbers.
5. Fill in the contact person's name and phone number for further inquiries.
6. Select the effective date of the change and today’s date.
7. Ensure that an authorizing signature is included; this is required from the physician or office manager.
8. Complete the 'Provider Change Information' section by checking all types of changes being made, such as adding a practice or changing an office location.
9. Provide complete previous office information and new office information, including addresses, city, state, zip, phone number, and fax number.
10. Indicate if there are any name or tax ID changes.
11. Fill out the 'Physician Members' section, checking whether to add or delete each individual provider's information including their last name, first name, middle name, NPI, effective date, taxonomy code, and degree.
12. If applicable, complete the 'Change of Ownership' section, providing the legal business name of the new owner and the effective date.
13. Attach any necessary supporting documents, like a new W-9 form, if pertinent to the changes.
14. Review the form for completeness and accuracy. Once finalized, save the changes, download or print the form, and be prepared to mail or fax it to the specified address.

Complete your documents online today and ensure your practice information is accurately updated.