Get Request To Change Particulars Enrolled Health Care Provider Using The Ehealth System. Request To

Filling out the Request To Change Particulars Enrolled Health Care Provider form is essential for updating information in the eHealth system. This guide provides clear, step-by-step instructions to ensure that users can fill out the form accurately and efficiently.

Follow the steps to complete your change request successfully.

1. Click ‘Get Form’ button to acquire the form and open it in your editor.
2. Begin by providing the present particulars of the enrolled health care provider (EHCP). Fill in the 'Name of EHCP' and 'Name of Medical Organization' fields clearly.
3. Indicate the change requests by checking the relevant boxes under section (A) for personal particulars. Fill out the correspondence address, contact email address, daytime contact telephone number, and fax number as applicable.
4. Complete section (B) for the particulars of the medical organization, providing the same details as in step 3.
5. In section (C), specify any practice details and service fees you wish to update. You can select to remove or add a practice under EHCP's enrolment. Optionally fill in the reasons for removal and select the schemes/programmes related to these practices.
6. If applicable, fill out section (D) for bank details changes, ensuring to include any required documentation as noted.
7. Use section (E) to indicate if you wish to withdraw from any schemes and provide reasons if desired.
8. Complete section (F) for any other requests or details not yet covered.
9. Ensure that the form is signed by the enrolled health care provider and authorized signatory, including printed names and dates.
10. Finally, review the entire form for completeness, then save your changes, download the document, print, or share it as needed.

Complete your changes online to ensure your health care provider information is up to date.