Life’s constant changes often require formal updates in personal and professional situations, particularly when it involves a change of address. Whether for an individual professional or an organization, updating contact information is crucial to maintain the smooth operation of services, delivery of correspondence, and compliance with legal requirements. The Change of Address form serves as a standardized method for notifying pertinent parties of an address change, ensuring that mail and other important communications are accurately directed to the new location. This form typically covers various aspects, such as specifying whether it's an addition or a change of an existing location, the effective date of the change, details about the new office location including accessibility features, and if applicable, new billing and mailing addresses. It also mandates providing specific personal and professional identifiers such as Social Security Number (SSN), National Provider Identifier (NPI), and Tax Identification Number (TIN). Moreover, the requirement of a certification signature from the TIN owner/representative underscores the form's role in validating the authorization for such changes, especially pertinent to financial transactions and service billings. To accommodate the diverse needs of professionals and organizations, the form also inquires about additional practice locations and prompts the attachment of a corresponding list, ensuring a comprehensive update is captured. Filing this form via fax or mail is not just a procedural task but a critical step in safeguarding the continuity of services and regulatory compliance.
| Question | Answer |
|---|---|
| Form Name | Change Of Address Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | humana com change of address, humana provider change of address form, humana provider address change, humana address change |
CHANGE OF ADDRESS FORM
RETURN COMPLETED FORM VIA FAX TO:
Provider Name (please print): Last_______________________________ First______________________ MI_______
Provider Social Security #:
Provider NPI for SSN:
Please check one: ADD location CHANGE location or information
EFFECTIVE DATE: ______________________ Allow 30 days from receipt date for processing
NEW OFFICE LOCATION: Is this a new Primary Location? Yes No Address:
*No PO Boxes*
County: __________________ Email: ______________________________________________
Phone Number: ( |
) ________________________ Fax: ( |
) ______________________ |
Tax ID #:
NPI for this Tax ID
*Submit
Designated Primary Address for NPI:
Tax I.D. Name (must match
Hours at this Location
Mon
Tues
Wed
Thurs
Fri
Sat
Handicapped Accessible? Yes No Public Transportation Accessible? Yes No
A certification signature from the TIN owner/representative is required if applicant requests payment to a TIN assigned to another individual, corporation or partnership to authorize payment to the TIN owner, for TRICARE services rendered by applicant.
N/A TIN is assigned to applicant
TIN is assigned to another individual or entity
Authorization Signature by TIN Owner/Representative
NEW BILLING ADDRESS:
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Phone Number: ( |
) __________________ |
Fax: ( |
) ______________________ |
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LOCATION(S) TO DELETE: |
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TAX ID#(S) TO DELETE: |
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DOES MAILING ADDRESS CHANGE? Yes |
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No |
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IF YES, NEW MAILING ADDRESS: |
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Phone Number: ( |
) __________________ |
Fax: ( |
) ______________________ |
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DO YOU CURRENTLY HAVE ADDITIONAL PRACTICE LOCATIONS? Yes |
No |
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IF YES, PLEASE ATTACH LIST. |
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Form Completed By (please print): |
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Date: |
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NET: 01/10: Revised 01/13; 07/13