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Get Buckeye Health Plan Facility/agency Change Form 2018-2026
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How to fill out the Buckeye Health Plan Facility/Agency Change Form online
Filling out the Buckeye Health Plan Facility/Agency Change Form online is an essential process for updating or changing your facility or agency information. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.
Follow the steps to complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Start by entering today's date and the effective date of change in the required fields at the top of Section A.
- Fill in the facility or agency name as it appears on the W-9, alongside the Medicaid number and NPI.
- Continue by providing the Medicare number, type of facility or agency, phone number, TIN, and taxonomy in Section A.
- In Section B, specify the type of change you are making: whether deleting, updating, or adding a location, and complete the relevant subsections Ia, Ib, Ic, II, and III as applicable.
- If changes affect billing information, proceed to Section D and enter the new billing address, along with the required contact details.
- Complete Section C for accreditation and licensing, attaching any necessary documents.
- If there is a change in taxonomy, fill out Section E with the current and new taxonomy information.
- Before submitting, review your form for accuracy, then click the submit button at the end of the form to return it to the Buckeye Health Plan.
- You may save the changes, download, print, or share the form as needed.
Complete your Buckeye Health Plan Facility/Agency Change Form online today for efficient processing.
Selecting the best health plan for Medicaid often comes down to personal needs and preferences. Buckeye Health Plan stands out for its extensive resources and comprehensive support structure. To ensure coverage that fits your situation, consider using the Buckeye Health Plan Facility/Agency Change Form, which allows you to adjust your plan as needed.