Get Provider Change Form - Amerihealth

This guide offers clear and comprehensive instructions on completing the Provider Change Form for AmeriHealth online. Follow the outlined steps to ensure your form is filled out accurately and efficiently.

Follow the steps to complete the Provider Change Form.

1. Press the ‘Get Form’ button to access the Provider Change Form and open it in your preferred editing tool.
2. In the section labeled 'Current Practice Information', indicate whether the change affects a group practice or an individual physician by selecting the appropriate option. Enter the name of the group practice or individual physician and their NPI effective date in the provided fields.
3. Complete the Provider ID and HMO/PPO ID fields with the relevant identification numbers for the practice or physician changing information.
4. Provide the contact person’s name and phone number, ensuring that this information is accurate for follow-up communications. Note that a signature is required to complete the form.
5. Fill in the effective date of the change and today’s date in the specified format.
6. In the 'Provider Change Information' section, choose the type of change being made such as adding a practice or changing an office location. Check all applicable options.
7. Provide complete previous office information, including name, address, and contact details. Then, enter the new office information in the corresponding fields.
8. If you are adding or deleting individual providers from your practice, check the appropriate boxes and fill in the required identification information for each provider, including their NPI and taxonomy code.
9. If applicable, complete the 'Change of Ownership' section with the legal business name of the new owner, effective date of change, and tax ID number. A new W-9 form may be required.
10. After filling out all necessary sections, review the information for accuracy. Save the changes, and you will have the option to download, print, or share the completed form.

Complete your Provider Change Form online today to ensure your information is updated efficiently.