Get Provider Update Form - Easy Choice Of New York

This guide provides clear, step-by-step instructions on how to complete the PROVIDER UPDATE FORM for Easy Choice Of New York. Ensuring that your information is accurate and up-to-date is essential for efficient processing.

Follow the steps to fill out the PROVIDER UPDATE FORM online.

1. Select the ‘Get Form’ button to access the PROVIDER UPDATE FORM and open it for editing.
2. Choose the applicable boxes for the type of provider—Commercial or Medicare—by marking the appropriate selections.
3. Fill in the provider name and provider NPI (National Provider Identifier) in the designated fields.
4. Indicate the type of provider, selecting from options such as PCP (Primary Care Provider) and SPC (Specialist). You will also need to enter the Provider Medicare number and CAQH number if applicable.
5. For group practices, enter the group name and group NPI numbers in the provided sections.
6. Specify your specialties in the Specialty 1 and Specialty 2 fields, and list any relevant languages spoken.
7. Under Service Location(s), choose whether to add, update, or terminate location details, and indicate if the panel is closed to new patients.
8. Fill out the address and access details for the service location, ensuring to include any relevant contact information such as phone and fax numbers.
9. Enter the practice name, street, city, state, zip code, and office hours in the specified fields.
10. Provide details on hospital affiliations and the office manager, including relevant contact information and email addresses.
11. Complete the Payee/Billing Information section, selecting whether it’s new, terminating, or additional billing and entering tax ID numbers where required.
12. Review the form carefully to ensure all information is correct, then proceed to save your changes, download, print, or share the completed form as needed.

Complete your provider update form online today to ensure your information is current and accurate.