Get Gateway Health Plan Practice/provider Change Request Form

This guide provides clear, step-by-step instructions on how to fill out the GATEWAY HEALTH PLAN Practice/Provider Change Request Form online. It is designed to assist users in completing the necessary fields accurately for practice changes.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to access the form and open it for editing.
2. Fill out the practice information, including the Gateway ID#, practice name, federal tax ID#, specialty, contact person name, and contact person phone.
3. Identify what is changing by checking all applicable boxes under 'What is Changing?' Ensure to attach any required documentation, such as a W9 form where indicated.
4. Complete Section A, providing the effective date, physician name (if applicable), practitioner ID#, and NPI#. Specify if the location is new or existing.
5. For any billing or tax ID changes, complete Section B, entering the old and new billing name and tax ID, along with the relevant address details.
6. If associated with Medicaid or Medicare Assured, fill out Section C with the necessary current and new information regarding panel status and age restrictions.
7. For terminating a physician, complete Section D with the effective date, physician name, reason for termination, and new address (if relocating).
8. Once all sections are filled out accurately, review the document for completeness and correctness before saving changes, downloading, printing, or sharing the form.

Complete your documents online today for a smooth practice change process.