Get Provider Address Change Request Form - Home Iowa ... - Dhs Iowa

Filling out the Provider Address Change Request Form is essential for ensuring that your provider information is accurate and up to date. This guide offers a step-by-step approach to help you navigate the form and submit it online with confidence.

Follow the steps to accurately complete the address change request form.

1. Click the ‘Get Form’ button to access the Provider Address Change Request Form. This will allow you to start filling out the document in the designated editor.
2. Begin by entering your provider name in the designated field at the top of the form.
3. Input your National Provider Identifier (NPI) number accurately to ensure your information is correctly linked.
4. If applicable, enter the Taxonomy code only if your NPI represents a group. This information helps categorize your services.
5. Provide your Tax ID or Social Security Number in the corresponding field, as required for identification purposes.
6. Enter the contact phone number of the individual who is completing the form. Note that this is for communication purposes and will not update any existing records.
7. Complete the section for your physical address, making sure to enter the new physical address where services will be provided. Remember that this cannot be a P.O. Box.
8. Fill out the zip code in the provided nine-digit format to ensure proper mail delivery.
9. If you're changing your address to a different state, remember that re-enrollment is required. You can contact the IME Provider Enrollment Unit for assistance.
10. Provide your current and new 1099 address in their respective sections, which is necessary for correct financial correspondence.
11. Fill out the correspondence address section, ensuring both current and new addresses are entered correctly for all provider correspondence.
12. Lastly, sign and date the form at the end. Your signature and date are required for processing your address change request.
13. Once you have completed the form, you can save your changes, download a copy, print it for your records, or share it as needed.

Start filling out your Provider Address Change Request Form online today to keep your provider records accurate.