Follow the steps to complete your application form successfully.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred electronic editor.
2. Before filling in any information, review your current demographic data to ensure the changes you wish to request align with our existing records. You can do this online. This step is crucial for minimizing errors.
3. Complete all mandatory fields in Section 1, which includes your name, Medicaid and Medicare numbers, NPI, Tax Identification Number (TIN), and effective date for the requested changes. Make sure effective dates comply with the given conditions.
4. If you are adding a new TIN, ensure to complete Section 1 and sign and date a W-9 form. If you are deleting an existing TIN, indicate that in Section 1 and ensure at least one active TIN remains.
5. Fill out Section 2 if you are changing any demographic information along with the TIN. Students who are not current with their records will not be able to complete this part.
6. Provide complete practice location information including address, contact details, and facility type in the subsequent sections as required.
7. Complete any additional non-primary practice location or billing address sections as applicable. Be sure to designate if the address is a private residence or an inpatient facility.
8. Review all entries for accuracy. Ensure all information matches the details on file with the IRS or social security administration. Mismatches can delay processing.
9. Sign and date the authorization and release section, certifying that the information provided is accurate and complete.
10. Once you have completed the form, save your changes. You can choose to download, print, or share the document depending on your next steps.

Complete your application form online today to ensure timely processing of your changes.