Get Provider Information Change Form - Healthcare Administrative ... - Hcasma

This guide provides a comprehensive overview of completing the Provider Information Change Form online. This form simplifies the process of communicating changes to health plans, ensuring that your practice information remains current and accurate.

Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to obtain the form and open it for filling out.
2. Indicate the changes being submitted by checking all applicable boxes in the designated section. Remember to include the effective date for each item you check.
3. Provide your personal information in the provider information section, including your last name, first name, middle initial, former name (if applicable), NPI number, PTAN number (if applicable), and tax ID number.
4. Complete the practice/business name, street address, city, state, phone number, fax number, and zip code in the provider information section. Don't forget to include your provider email address.
5. If applicable, attach a separate list with the names and NPI numbers of all providers in the group for whom the address change applies.
6. In the address information section, enter any new or additional addresses. Specify the type of address (primary, billing, secondary, or mailing), including the address details.
7. If you have old addresses to terminate, provide those as well, marking the type of address and entering the corresponding details.
8. If applicable, complete the primary care panel status section, noting whether the panel is open, closed, or has other specifications.
9. If you're reporting a termination, indicate the reason by checking the appropriate box. If applicable, provide extra details in a separate explanation.
10. Finally, fill in the contact person submitting the information, including their name, title, phone number, fax number, email address, and date of submission.
11. Once you have completed the form, ensure all required sections are filled out and save your changes. You can then download, print, or share the form as needed.

Complete your Provider Information Change Form online today to ensure accurate and up-to-date information for your practice.