Get Change Request Form Organization Maintenance - Availity

The Change Request Form Organization Maintenance - Availity is designed to facilitate updates to your organization’s information within the Availity system. This guide provides clear, step-by-step instructions to assist users in accurately completing the form online.

Follow the steps to complete your Change Request Form.

1. Press the ‘Get Form’ button to retrieve the form and access it for editing.
2. Input your organization information as currently recorded in Availity. This includes the organization name, customer ID, city, state, and the last name of the primary controlling authority (PCA). Ensure all fields are filled out accurately.
3. In the 'Change Organization Identifiers' section, decide if you need to add or delete an identifier. Mark the appropriate checkbox for either Add or Delete. If you need to change an existing identifier, complete two rows: one to delete the old identifier and another to add the new one. If more space is needed, additional pages may be utilized.
4. Under 'Identifier Type,' select either the NPI or Tax ID checkbox corresponding to the identifier you are adjusting. Then, enter the NPI or Tax ID in the Identifier field.
5. In the 'Change Organization Type' section, select the checkbox next to your new organization type. Pay attention to the selection, as different types have varying features within Availity.
6. Ensure the PCA initials are filled in where required. This is a necessary step for validation.
7. For changes in geographic locations, if applicable, remember to contact Availity Client Services directly for proper account updates.
8. In the signatures section, the PCA must sign and date the form, providing attestation to the information's accuracy. A witness, who is not listed in the document, should observe the signing and provide their signature and date. Ensure that dates match.
9. Finally, submit the completed form either by faxing it to Availity Security or mailing it to the provided address. Make sure to keep a copy for your records.

Begin filling out your Change Request Form online today to ensure your organization’s information is up to date.