Follow the steps to successfully complete the application.

1. Click the ‘Get Form’ button to access the application and open it in the editor.
2. Review your current demographic information online to ensure consistency with the changes you are about to make. This helps avoid delays.
3. Complete Section 1, which requires essential identification details like your last name, first name, individual Medicaid number, and Tax Identification Number (TIN). Make sure to select the appropriate reason for change.
4. If you are adding a new TIN or practice information, fill out the sections relevant to those changes, ensuring each section is accurately filled out.
5. For location changes, complete Sections 2 and 8, providing the new practice address and any updated license information.
6. If updating your demographic information only, complete Section 1, as well as any other applicable sections to reflect the changes you need.
7. Attach necessary documents such as a signed and dated W-9 form if adding or changing a TIN, or a DEA registration for prescription privileges. Ensure you have only one address listed.
8. Once all sections are completed and checked for accuracy, save your changes. You can then download, print, or share the completed form as needed.
9. Finally, submit the signed form and any attachments to the appropriate network management team as instructed.

Complete your CA Clinician Add/Change Application online today to ensure your information is up-to-date.