Get Ok Network Change Form 2018-2025

Filling out the OK Network Change Form online is a straightforward process designed to help users update facility information efficiently. This guide will walk you through each section of the form, ensuring you complete it accurately and submit it without any issues.

Follow the steps to successfully fill out the OK Network Change Form

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the facility name and specialty in the designated fields at the top of the form.
3. Provide the new physical address in the appropriate section. Ensure all necessary details are included for accurate processing.
4. Fill out the new mailing address. If there are additional physical addresses, list them on a separate sheet and attach it.
5. Enter the phone and fax numbers related to both new addresses. Providing accurate contact information is crucial.
6. Specify the contact person for the facility and their email address to facilitate communication.
7. Complete the new billing address section along with the Tax ID Number (TIN). If applicable, attach a completed W-9 Form.
8. Indicate whether the TIN or NPI number has changed with the new address and provide previous numbers if necessary.
9. Provide the effective date of the new address and complete the former physical address section if an address change is occurring.
10. If this is an additional location, specify that by selecting 'Yes' or 'No'. Complete the details of the former billing address, including the phone number and termination date.
11. Include the contact name for authorization and provide their authorized signature along with the date.
12. Once all sections are completed, review the form for accuracy. You may then save changes, download, print, or share the form as needed.

Complete your document online today for a seamless update process.