Follow the steps to complete the Provider/Facility Update Form online.

1. Press the ‘Get Form’ button to acquire the form and open it in the editor.
2. In the 'Name' field, enter your full name as it appears in your professional documentation.
3. Enter your email address in the designated field to ensure you receive any relevant notifications.
4. Fill in your Tax Identification Number (Tax ID) in the appropriate section.
5. Provide your National Provider Identifier (NPI) number to assist with your identification.
6. Indicate the locations where you are currently seeing patients. For each location, fill in the street address, suite number (if applicable), city, state, and zip code. Do not forget to provide a phone number and fax number for each location.
7. List the locations where you are no longer seeing patients, similarly filling in all required fields for each past location.
8. If applicable, enter any Tax ID numbers you are no longer using.
9. Note that a change of address requires an accompanying W-9 form. Ensure to obtain this form if necessary.
10. Once you have completed all sections, you can save your changes, print the form, or share it as needed. Remember to fax the completed form to 1-888-979-9272, email it to providerrelationsteam@ndbh.com, or mail it to the address provided.

Start updating your information online by completing the Provider/Facility Update Form now.