Get Provider Information Change Form - Rightcare From Scott & White ...

This guide provides detailed instructions for completing the Provider Information Change Form specific to RightCare From Scott & White. Follow these steps to ensure accurate submission of your provider information changes online.

Follow the steps to successfully complete your Provider Information Change Form.

1. Press the ‘Get Form’ button to access the Provider Information Change Form and open it in your preferred document editor.
2. Begin by entering the date in the format of MM/DD/YYYY at the top of the form. This is crucial for processing your request accurately.
3. Fill in your Nine-Digit Texas Provider Identifier (TPI), National Provider Identifier (NPI), Atypical Provider Identifier (API), Primary Taxonomy Code, and Benefit Code as applicable. Make sure these identifiers are correct to avoid any delays.
4. If your provider information includes multiple TPI numbers, list them in the designated sections provided on the form. Ensure to enter each TPI accurately.
5. Complete the Physical Address section, noting that the address must not be a PO Box. Enter the Street Address, City, State, County, Zip Code, Telephone, and Fax Number as necessary.
6. Provide your email address in the designated field for any follow-up communication.
7. If you are changing your Accounting/Mailing Address, fill out that section and remember to attach a copy of the W-9 Form.
8. Indicate any Secondary Address if applicable, filling in the corresponding fields similar to the Physical Address section.
9. Select the Type of Change by checking the appropriate box to clearly communicate the nature of your request.
10. In the Comments section, provide any additional context, especially for changes in provider status or unique circumstances.
11. Add your Tax Identification (ID) Number and the exact name reported to the IRS for that ID. This is essential for validating your information.
12. Complete the Provider Demographic Information section by listing languages spoken, office hours, and patient acceptance criteria as required.
13. Finally, sign and date the form. Note that the form will not be processed without the provider’s signature.
14. Once you have filled out all necessary sections, save your changes, and you may proceed to download, print, or share the form as needed.

Complete and submit your Provider Information Change Form online today to ensure your practice details are up to date.