Get Provider Demographic Information Change Request Form1199seiu Funds

Filling out the Provider Demographic Information Change Request Form is essential for maintaining accurate records with the 1199SEIU Funds. This guide will provide you with clear and detailed instructions on how to complete the form online, ensuring that your information is processed efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether you are a participating or non-participating provider by checking the appropriate box at the top of the form.
3. In the 'Current Provider Information' section, fill in your provider name, email address(es), specialty, area of interest, NPI, and tax ID. Ensure accuracy to avoid processing delays.
4. Indicate if you are board certified and whether your office meets ADA accessibility requirements by selecting 'Yes' or 'No' for each question.
5. In the 'Provider Change Information' section, select the type of change you are making. You can check more than one option, such as changes related to billing addresses, service addresses, or provider languages spoken.
6. Fill in the date the change will take effect, using the MM/DD/YYYY format.
7. Complete the 'New Service Information' section, indicating whether this is your primary service location.
8. Provide the new billing information. Ensure that you include the name as shown on your income tax return, address, telephone, fax, tax ID, and NPI.
9. If applicable, fill in the old demographic and service information for reference.
10. At the bottom of the form, include your printed name, title, authorized signature, date, email address, telephone, and fax number.
11. Once you have filled in all required information, review the form for accuracy. Save your changes, then download, print, or share the form as needed.

Complete your Provider Demographic Information Change Request Form online today for prompt processing.