Get Provider Update Form-revised - Dentaquest

Filling out the Provider Update Form-Revised - DentaQuest online is a straightforward process that helps ensure your information is current and accurate. This guide will provide you with clear, step-by-step instructions for each section of the form.

Follow the steps to complete the Provider Update Form-Revised online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. In Section 1, Current Information, please fill out your last name, first name, Individual National Provider Identifier (NPI) number, telephone number, and credentialing email. Ensure that all information provided is accurate and up to date.
3. Move to Section 2 for Name Change/Demographic Change, if applicable. Enter your new name (last, first, middle initial), new telephone number, date of birth, new credentialing email, social security number, new fax number, and gender.
4. In Section 3, Add a Location, provide the location name, service location address, city, state, telephone, zipcode, credentialing email, fax, tax ID number, new location office hours, ages served, and effective date. Make sure to include information regarding handicapped accessibility and the primary location.
5. Proceed to Section 4 for Credentialing Correspondence Address Change. Enter the credentialing contact name, credentialing address, city, state, telephone, zipcode, credentialing email, and fax number.
6. In Section 5, Tax ID Change, provide the old tax ID number, new tax ID number, business name, and payment address. Attach the updated W9 and contract if necessary.
7. For Section 6, Provider Status Change, indicate if you are terminating a provider at specific locations or all locations. Fill out the location name, service location address, city, state, and reason for termination. Attach any necessary documents.
8. In Section 7, Requestor Information, include the requestor name, title, and phone number.
9. Finally, in Section 8, Notes, fill in the date, an email address, and zipcode. Ensure that you have included any additional locations or updates as required.
10. After completing all sections, review the information for accuracy. Save your changes, and if needed, download, print, or share the form as required.

Complete your documents online today to ensure your information is always up to date.