Get Anthem Professional Individual/professional Group Change Request Form 2016-2025

Filling out the Anthem Professional Individual/Professional Group Change Request Form online is essential for ensuring that patient data remains accurate and up-to-date. This guide provides clear instructions to help you navigate through each section of the form effectively.

Follow the steps to complete the change request form online:

1. Press the ‘Get Form’ button to access the Anthem Professional Individual/Professional Group Change Request Form and open it in your preferred online editor.
2. In the 'Provider/Group Name' section, enter the current name of your practice as it is officially registered.
3. Provide the license number associated with the practice in the 'License #' field.
4. If applicable, fill in the 'New Provider/Group Name' to reflect any changes in your practice's name.
5. Enter the NPI (Type 1) number in the designated field. This number is unique to individual practitioners.
6. If you have a Type 2 NPI, input it in the corresponding field.
7. List the previous Tax ID number under the 'Previous Tax ID' field.
8. Input the new Tax ID number if there has been a change in your Tax ID.
9. Indicate the effective date of the new Tax ID in the provided section.
10. If applicable, specify the hospital admitting privileges by checking 'Add' or 'Delete' for each of the privileges listed.
11. Indicate the status of the admitting privileges by selecting from the options provided, such as Active, Affiliate, Courteous, Associate, Provisional, Temporary, or Full.
12. Provide details regarding any specialties and indicate whether you are accepting new patients by checking Yes or No.
13. Indicate whether your facility has handicapped accessibility and ADA accessibility.
14. List the languages spoken by the provider and at the practice.
15. Fill out details about any providers leaving the practice along with their date of departure and reason for leaving.
16. Complete the practice address fields, including previous and new information as applicable.
17. Enter the telephone and fax numbers, as well as the email address for the practice.
18. List the practice office hours in the designated segment.
19. If there is a change in the payment address, include the previous and new address along with the respective contact information.
20. Submit the form by saving the changes, and choose to download, print, or share the form as needed.

Complete your Anthem change request form online to ensure accurate information for your patients.