Get Coa Form

Filling out the Coa Form online is a straightforward process that requires attention to detail. This guide will walk you through each section and field, ensuring you complete the form accurately and effectively.

Follow the steps to successfully complete the Coa Form online.

1. Click the ‘Get Form’ button to access the Coa Form and open it in your preferred editor.
2. Begin by filling in your first name, middle initial, and last name as they appear in official documents.
3. Enter the new clinic name or doing business as (DBA) if it differs from your previous clinic name.
4. Provide your OptumHealth 6-digit provider ID number and the old clinic name or DBA.
5. Indicate whether this notification concerns a new location or an additional office by circling the appropriate option.
6. Fill out the new clinic/site address change fields, including the effective date and old address details.
7. Specify if this location is your primary location by selecting yes or no.
8. Input the last date of service at the prior location and TAX ID numbers accurately.
9. Complete the fields requesting the new mailing/correspondence address, including suite numbers and city, state, and zip code.
10. Provide the new check/remittance advice address, ensuring that all details are filled correctly.
11. Enter your new phone, fax, and email information, as well as the old corresponding details.
12. List the NPI number(s), Medicare number, and Medicaid number in the designated fields.
13. Complete the section for other health care providers practicing in this office, if applicable.
14. Fill out new/additional office information, including office hours and patient demographics, as required.
15. Sign and date the form, then include your printed name.
16. Once all sections are completed, review to ensure accuracy, then save changes, download, print, or share the completed Coa Form as necessary.

Take a moment to complete your Coa Form online now and streamline your document management process.