Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date submitted at the top of the form to indicate when you are filing your changes.
3. In the group information section, provide details regarding the legal name of the group, clinic name, TIN, and other relevant identifiers, such as Medicare and Medicaid numbers. Indicate whether you have a core provider agreement.
4. Select the type of change necessary by typing 'yes' next to any applicable options under mailing information, clinic information, billing information, or other changes.
5. Provide specifics about old information. Include the effective date of any closures or changes and type the clinic name and address. Be sure to fill in the contact details and TIN.
6. In the new information section, enter the effective date for openings or changes, along with the new clinic name, address, and other relevant details. Confirm the accessibility options available at the clinic.
7. Complete the additional information section, including comments or notes about any changes to NPI numbers. Add your contact details, including name, phone number, and email.
8. Attach a list of all affected providers along with their corresponding individual NPI numbers.
9. After carefully reviewing the completed form for accuracy, proceed to save any changes, and download, print, or share the form as needed.

Take action now and complete your WA CHPW Clinic And Group Changes Form online to ensure your clinic remains up-to-date.