Get Behavioral Health Practice Update Form - Anthem

Completing the Behavioral Health Practice Update Form - Anthem is essential for ensuring your practice information is current and accurate. This guide provides clear, step-by-step instructions to assist you in filling out the form online with ease.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Enter the Tax ID in the designated field. Only provide one Tax ID per form, and note that a W-9 form is required for any Tax ID changes.
3. Fill in the name of the practice. Ensure it accurately reflects the official name as registered.
4. Indicate whether you are accepting new patients by selecting ‘Yes’ or ‘No’. Provide a valid e-mail address, as it is mandatory.
5. Complete the Check/EOB/Remit Address section. This is where reimbursements or payments should be sent. Make sure to provide the complete address, including city, state, zip, phone, and fax numbers.
6. Enter the Rendering NPI (Type 1) and License number as required.
7. If applicable, provide your BACB Certification number.
8. If there are additional addresses associated with the Tax ID, complete the necessary information for each one. Use the ‘ADD’ feature if adding more addresses.
9. For Office Address 1 and 2, provide the physical practice address. Remember, home offices are not permitted.
10. The practitioner’s signature is required. Ensure that the date is also filled in accurately.
11. Once the form is fully completed, save your changes. You can download, print, or share the form as needed.

Complete your Behavioral Health Practice Update Form - Anthem online today to ensure your practice information is up to date.