Get Provider Demographic Change Form - Healthnow New York

Filling out the Provider Demographic Change Form is an essential step for healthcare providers to update their information and ensure accurate records. This guide will provide clear, step-by-step instructions on how to efficiently complete the form online, making the process straightforward and accessible.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form online and open it for editing.
2. Begin with Section I: Demographic Data. Fill in your name, including last name, first name, and middle initial. Specify your title using the provided options.
3. Input your group or facility name along with your NPI number and optional ethnic information, which can assist in the referral process.
4. Move to Section II: Data Change Summary. Indicate the purpose of the change by checking the appropriate boxes, such as adding a location or changing your address.
5. Provide effective dates for any changes and include required information such as Tax ID and specialty details at the new site if applicable.
6. Continue to Section III: Data Change Detail. List both new and old information for any changes, ensuring clarity for each entry.
7. Proceed to Section IV: Wheelchair Accessibility, marking how wheelchair-dependent patients will be accommodated if applicable.
8. In Section V: On-Call Physician Coverage, enter details about on-call physicians if you are a solo practitioner or if relevant.
9. Complete the form by signing at the bottom and noting your contact information for any follow-up.
10. Once all sections are thoroughly filled out, save your changes, download a copy for your records, and print or share the completed form as necessary.

Ready to update your information? Start filling out the Provider Demographic Change Form online today!