Ntly contracted TIN and location(s). Please enclose a letter indicating specific changes including effective date, practice name and tax identification number with which you are no longer affiliated** Effective date Complete all sections Changing current demographic location only Complete information below only as it pertains to changing currently contracted location(s)/state and there is no change to the TIN currently on file. Please enclose a letter indicating old.
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How to fill out the CA Clinician Add/Change Application Form online
The CA Clinician Add/Change Application Form is an essential document for clinicians looking to update their participation status with United Behavioral Health/US Behavioral Health Plan, California. This guide provides step-by-step instructions to help users navigate the online version of the form effectively.
Follow the steps to complete the CA Clinician Add/Change Application Form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Review the application checklist carefully to ensure all required information and supporting documents are ready for submission.
- Fill in your personal information in the designated fields, including your last name, first name, middle name, previous surname, social security number, date of birth, gender, degree, NPI, and email address.
- Indicate whether you are changing your tax identification number or demographic location by selecting the appropriate options and providing an effective date.
- Complete the section for new office locations, answering questions about the practice address, contact information, and clinic details.
- If applicable, provide the remit/billing address separately from the primary clinic address. Fill out the necessary information accurately.
- For tax information, specify the address for 1099 if different from the billing address. Ensure all contact information is current.
- Include any changes in hospital admitting privileges, professional liability insurance, and state-controlled substance permits if applicable.
- Review your entire application for any errors or missing information to avoid delays.
- Once you are satisfied with the application, save your changes and choose to download or print the completed form for submission.
Complete your CA Clinician Add/Change Application Form online today to ensure timely processing of your updates.
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