Get Provider Change Form - Priority Health

Filling out the Provider Change Form for Priority Health is an important process for healthcare providers when there are changes in participation. This guide provides a comprehensive, step-by-step overview of how to properly complete the form online.

Follow the steps to successfully complete the Provider Change Form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the 'About the change' section, provide a brief explanation of the change. Fill in the physician name, group or facility name, current tax ID, NPI number, and the date.
3. Enter the name, phone number, and email of the person completing the form. Choose the type of change that is applicable (e.g., leaving a participating provider group). Be aware that written notice is required 90 days in advance.
4. Specify if you are leaving a network and provide the reason for leaving. Indicate if extension of care applies and choose the appropriate options for HMO/POS or EPO/POS.
5. If applicable, indicate if the physician is deceased, retiring, on a leave of absence, or moving. Provide the effective date for this change.
6. For demographic changes, fill out the new address details, including the name to display on the door, term dates, and address types. Specify if the new address should be listed in the online provider directory.
7. Report name, tax ID, or NPI changes with their effective dates. Include a W-9 form where required.
8. If an age panel limit change is necessary, specify the new age panel limits applicable to the practice.
9. For open/close status changes, ensure Priority Health receives this change at least 60 days prior to the effective date.
10. List any additional facility services that will be provided. Confirm all required information is complete before submission.
11. Fax or email the completed form to the Provider Information Management department at the provided contact details.

Start completing your Provider Change Form online now.