Get Demographic Change And Provider Addition/deletion Request Form

Completing the demographic change and provider addition/deletion request form online can streamline the process of updating healthcare provider information. This guide will offer clear and concise instructions on how to accurately fill out each section of the form to ensure compliance and efficiency.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the basic information section for the PHP/group name, which identifies the primary health provider.
3. Next, provide the details for each health professional being added or removed, including their name, effective date, hospital affiliation, and contact information.
4. For each provider listed, specify their specialty and board certification information, as well as required demographic data such as gender, ethnicity, and languages spoken.
5. Indicate the days and hours of operation, along with any relevant member restrictions or certifications (e.g., EPSDT certification).
6. Review all entries for accuracy and completeness. Ensure that each provider meets the credentialing criteria set forth by the managing organization.
7. Once the form is complete, save any changes made to the document. You may then download, print, or share the form as necessary to fulfill the submission requirements.

Start filling out the Demographic Change And Provider Addition/Deletion Request Form online now to ensure your information is up-to-date.