Get Standardized Provider Information Change Form - Health New England

Filling out the Standardized Provider Information Change Form for Health New England may seem straightforward, but it is essential to complete each section accurately to ensure your information is processed without delays. This guide provides a clear, step-by-step approach to help you navigate the online form.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Standardized Provider Information Change Form and open it in your online editor.
2. Begin by indicating the changes you are submitting. Check all applicable boxes for the changes (e.g., practice information, billing information, provider name) and include the effective date for each checked item.
3. Complete the provider information section by filling in the required details such as last name, first name, former name (if applicable), NPI number, and provider type. If applicable, make sure to include the practice or business name and contact details.
4. If the address is changing, enter new or additional addresses in the address information section. Indicate if it is a secondary, mailing, or billing address. Also, enter old addresses that need to be terminated.
5. In the primary care panel status section, specify your panel status by checking the appropriate box. This helps indicate the type of practice and its availability.
6. If applicable, provide the reason for any termination and complete the associated details. Check only one box and be sure to add any necessary explanations if required.
7. Fill out the contact person submitting the information section with the name, title, phone number, fax number, and email of the person completing the form.
8. Finally, save your changes, download, print, or share the completed form as needed.

Complete your documentation online today for a seamless update to your provider information.