Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Choose the request type by selecting 'Add', 'Delete', or 'Change'. Make sure to indicate the effective date of the change if applicable.
3. Provide the practitioner's new information in the appropriate fields, including last name, first name, middle initial, title, social security number, NPI number, gender, date of birth, and tax ID Number (TIN). Remember to submit a W-9 if there is a TIN change.
4. Indicate the specialties for the practitioner. You may list a primary specialty and a secondary specialty if applicable.
5. Specify whether the practitioner accepts new patients and any non-English languages spoken by them.
6. Enter practice information, including street address, city, zip code, and contact details. Clearly indicate the type of address as correspondence, billing/remittance, or physical.
7. Fill out the 'Make Checks Payable to' field.
8. Sign and date the certification at the bottom of the form to confirm that all information provided is true and complete.
9. Send all required documents, including copies of licenses and any additional information, to HWMG at the specified address. Be sure to include the signed authorization and release.
10. After completing the form, save your changes, download, print, or share the form as needed.

Take the next step by completing the Provider Add, Delete or Change Form online now!