Get Provider Demographic Information Change Request Form

This guide provides clear, step-by-step instructions on completing the Provider Demographic Information Change Request Form online. Whether you are a participating or non-participating provider, this resource will help you navigate the required fields and ensure your information is updated accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the Provider Demographic Information Change Request Form and access it in your preferred editor.
2. Begin by filling in your current provider information, including provider name, tax ID, specialty, and NPI. Ensure all entries are accurate to avoid any processing delays.
3. Indicate the type of change affecting your information by checking the appropriate boxes under the 'Provider Change Information' section, selecting one or more options as applicable.
4. Provide the effective date of the changes. This date should be formatted as month/day/year.
5. Complete the new demographic information section. Outline the new service location details, including whether it is a primary service location, individual name, group name, address, city, state, zip code, telephone, fax, and tax ID.
6. If necessary, complete the new billing information section. Remember to submit a W-9 form with any updates to your tax ID.
7. Review the old service information and old billing information sections. Fill these out if applicable to document previous details that are being changed.
8. Provide the print name and title of the authorized individual signing the form, along with their authorized signature and the date.
9. Finally, ensure you include your telephone number and email address, and submit the completed form via fax or email as instructed.

Take action today to update your provider information by filling out the form online.