Get Contracted Provider Update Form - Healthspan

The Contracted Provider Update Form - HealthSpan is a crucial document for contracted participating groups to communicate essential updates about their practice. This guide provides a clear, step-by-step approach to filling out the form effectively online.

Follow the steps to complete the Contracted Provider Update Form successfully.

1. Press the ‘Get Form’ button to access the Contracted Provider Update Form and open it in your document editor.
2. Begin by providing the general information in Section A. Enter the group or practice name, practice tax ID number, and group or practice NPI number.
3. Move to Section B to select the reason for submitting the form. Choose one option that best describes your situation, such as 'Add new provider to group' or 'Practice name change only.'
4. For Section C, if adding a new provider, list the full name and type of each provider who is applying for network participation. Include their CAQH number, NPI number, date of birth, board certification status, and any hospital affiliations.
5. In Section D, provide updates regarding existing provider information. Fill in first name, middle initial, last name, title, individual NPI number, CAQH number, provider Medicare number, and contact details for the current and new practice addresses.
6. For Section E, you may include any additional comments or information pertinent to your submission.
7. Complete Section F with your signature and the date to validate your submission, showing that the information provided is accurate.
8. In Section G, provide practice contact information, including the contact name, phone number, and email address.
9. Ensure that you gather and attach the required documents, such as the malpractice liability insurance face sheet and W-9 tax forms, if applicable.
10. Finally, save your changes, download the completed form, or print and share it as needed. Follow the return instructions to submit the form to HealthSpan.

Take action now and complete the Contracted Provider Update Form online to keep your practice information up to date.