Get Provider Change Form - Sunflower Health Plan

This guide provides clear instructions for completing the Provider Change Form for Sunflower Health Plan online. It covers each section of the form, ensuring you have the necessary information to submit your changes accurately.

Follow the steps to fill out your form correctly.

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter today's date and the effective date of the change in the designated fields at the top of the form.
3. Provide the facility or provider's legal name and attach a W9 form to verify all changes.
4. If applicable, fill in the DBA or clinic name along with the tax ID and group NPI number.
5. Indicate your licensure state and provide your phone number, medicaid number, taxonomy number, facility accreditation, and contact person's details including their email address.
6. Select the type of change you are reporting by checking the appropriate box and complete the corresponding section (A, B, C, D, E, or F) based on the nature of the change.
7. For section A (change in physical address, phone or fax), provide previous practice location details and new practice location information.
8. For section B (change or add of second location), complete the details as required and indicate if the tax ID changes.
9. For section C (change in billing address), provide the new billing address and confirm the attachment of a new W9 form.
10. For section D (change in mailing address), simply enter the new mailing address along with other required contact details.
11. In section E (change of provider status), provide a detailed explanation of the status change along with the effective date.
12. In section F (change in NPI or new NPI number), provide the necessary NPI information and ensure to include the facility name, address, taxonomy code, and issue date.
13. Sign and date the form before submitting it to the designated email address or by postal mail as indicated.

Complete and submit your Provider Change Form online today to ensure your information is up to date.