Get Institutional Provider Change Request Form - Anthem

Filling out the Institutional Provider Change Request Form - Anthem can be a straightforward process. This guide provides expert insight into each component of the form to help ensure that all necessary information is accurately provided.

Follow the steps to complete your request efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility or institution name in the designated space.
3. Input your Medicare/Anthem provider ID and National Provider Identifier (NPI) in the specified fields.
4. In the tax ID section, provide your current tax ID as well as your new tax ID if applicable, including the effective date of this change.
5. Complete the previous and new payment/check/EOB address fields accurately, ensuring that the city, state, and zip code are also filled in.
6. Fill out the previous and new mailing/correspondence address, along with the associated telephone and fax numbers.
7. Repeat the process for the physical address, ensuring to update any relevant telephone and fax numbers.
8. An authorized person must sign below the given signature field to validate the changes. Ensure their name and title are printed next to their signature.
9. Review all entered information for accuracy, and once confirmed, you may choose to save changes, download, print, or share the filled-out form.

Ensure accurate updates by submitting your Institutional Provider Change Request Form online today.