Get Tufts Provider Information Change Form

Filling out the Tufts Provider Information Change Form online is an essential process for ensuring that your provider information is accurately updated. This guide will walk you through each step, making it simple and straightforward for you to complete the form successfully.

Follow the steps to fill out the Tufts Provider Information Change Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling in your contact name and phone number in the designated fields.
3. Enter the provider's name and NPI (National Provider Identifier) number accurately.
4. Indicate the effective date of the change by filling in the appropriate date in the provided space.
5. Check all applicable boxes regarding the type of health plans associated with the provider.
6. If you are updating or adding an address, you will need to provide a premises liability binder for certain provider types. Make sure you have this document prepared.
7. For Address Change 1, select whether you are adding or removing an address, then fill in the street, city, state, and ZIP code. Indicate if there is handicap access, and provide the telephone number.
8. In Address Change 2, follow the same process as in step 7 for the second address if applicable, indicating the type of address being changed (practice, payment, or mailing).
9. Fill out the section for Other Changes, checking any applicable boxes and providing necessary additional information such as a name change or tax ID number.
10. Provide the signature authorizing the change and the date it was signed.
11. Finally, enter an email address to receive confirmation of the change and ensure all fields are completed before submission.

Complete your provider information change online today!