Get Staff Update Form

The Staff Update Form is essential for adding or terminating a provider from your practice or organization. This guide will help you understand how to fill out this form accurately online and ensure a smooth submission process.

Follow the steps to complete the Staff Update Form online effectively.

1. Press the ‘Get Form’ button to access the Staff Update Form and open it in your online editor.
2. Enter the legal name of the provider in the designated field. This is crucial for proper identification.
3. Input the tax ID number, which is necessary for any financial or legal processing related to the provider.
4. Fill in the contact name and phone number for follow-ups or clarifications regarding the submission.
5. Choose whether you are adding a new provider or terminating an existing one by selecting the appropriate option.
6. Specify the effective date of the action you are taking in the MM/DD/YYYY format.
7. Provide the provider’s name in the format Last, First MI.
8. Fill in the NPI number, degree type, and date of birth of the provider, ensuring the accuracy of each entry.
9. Indicate the specialty of the provider, which helps in their classification within your organization.
10. Select the gender of the provider using the designated option.
11. Complete the CAQH number and medical license number fields, along with their expiration dates.
12. Input the DEA license number and its expiration date if applicable.
13. Indicate whether the provider is board certified and whether they provide pre-natal or OB care.
14. Fill in the malpractice insurance details, including coverage span.
15. List any hospitals where the provider has admitting privileges.
16. Select from the Colorado Access lines of business that the provider accepts, ensuring that all relevant options are checked.
17. Specify if the provider is new or existing, and list the service locations they will work at.
18. Indicate the languages spoken by the provider, which can be vital for patient communication.
19. Input the name of the person completing the form and the date of completion in the MM/DD/YYYY format.
20. Once you have filled out all required fields, review the information for accuracy, and save your changes. You may download, print, or share the completed form as needed.

Start filling out the Staff Update Form online today to ensure your provider information is up-to-date.