Get Mn Uniform Practitioner Change Form Fillable

Filling out the Mn Uniform Practitioner Change Form Fillable online can be a straightforward process with the right guidance. This document is essential for managing the addition or removal of practitioners across multiple sites efficiently.

Follow the steps to complete the Mn Uniform Practitioner Change Form Fillable online.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen online editor.
2. Indicate whether you are adding or removing practitioners by selecting the appropriate option in the 'Site Location Addendum' section.
3. In the 'Additional Location(s) For' section, fill in the required details such as the last name, first name, middle initial, and social security number.
4. Choose between adding or removing the practitioner by checking the corresponding box for Clinic or Hospital listed in the 'ADD/REMOVE Practitioner' section.
5. Provide the name, phone number, and address of the clinic or hospital, including city, state, and zip code.
6. Enter the type 2 NPI for the site and the tax ID number in the designated fields.
7. Specify the effective date of the changes and if the directory should be suppressed by selecting 'Yes' or 'No'.
8. Detail the practicing specialty at this site and indicate if it is a primary site by checking 'Yes' or 'No'.
9. If applicable, indicate whether you want to remove all sites for this TIN by selecting the relevant option.
10. Provide the reason for removal, if applicable, and list additional practice locations to add or remove in the Site Location Addendum, attaching it to the main form.
11. Once you have filled out all necessary sections, save your changes, and choose to download, print, or share the completed form as needed.

Complete your documents online efficiently by following these steps.