Follow the steps to effectively complete the form

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your provider name in the designated field.
3. Select the type of provider from the provided options.
4. Indicate the changes you wish to make by checking the relevant box: adding/removing a practice address, updating correspondence or billing addresses, or removing a provider.
5. If you are adding or removing a practice address, please fill in the new practice address details, including street address, city, state, telephone number, fax number, and zip code.
6. Provide the federal tax ID number and NPI number associated with the new practice address.
7. Enter the effective date of the practice address change.
8. For correspondence address changes, specify if you are updating this address or if it is the same as the billing address.
9. Fill in the new correspondence address details and include the federal tax ID number and NPI number.
10. If applicable, select the reasons for a provider no longer being part of your practice and provide the effective date.
11. For billing address changes, indicate if you are adding or correcting an existing billing address and provide the necessary details, including the effective date.
12. Complete the provider certification section by signing and providing your printed name, title, date, email, and telephone number.
13. Once everything is filled out accurately, save your changes, and you can download, print, or share the completed form as needed.

Complete your ConnectiCare Provider Information Update Form online today to keep your records current.