Mn Uniform Change Form – Fill Out and Use This PDF

The Minnesota Uniform Practitioner Change Form serves a crucial role for healthcare professionals needing to update their demographic data or change their practice details, including adding or removing practice locations. This comprehensive form, revised in March 2009, is mandated for various credentialed practitioners such as ER physicians, pathologists, radiologists, and more, who wish to ensure their practice information is current and accurate within the Minnesota healthcare system. For those who seek to maintain or modify their professional details with ease, completing this form attentively is a significant first step.

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Mn Uniform Change Form PDF Details

In March 2009, the Minnesota Uniform Practitioner Change Form was revised to streamline the management of practitioner information across the healthcare sector in Minnesota. This comprehensive document facilitates the addition, removal, or modification of demographic data for credential practitioners including, but not limited to, Emergency Room Physicians, Pathologists, Radiologists, Anesthesiologists, Certified Registered Nurse Anesthetists (CRNA), Neonatologists, Dietitians, Therapists (Physical, Occupational, Speech-Language), and Audiologists. It mandates specific details about the practitioner such as their name, social security number, professional titles, date of birth, gender, language fluency, practicing specialty, and essential identifiers like DEA, NPI, and Medicaid ID numbers. Clinic or hospital affiliations can also be updated through this form, requiring information on practice locations' addresses, tax identification numbers, and the effective dates for any changes. An additional Site Location Addendum Form is provided for practitioners changing associations with more than three sites, ensuring all necessary information is accurately captured and processed effectively. This documentation is crucial for maintaining accurate directories and ensuring compliance with various regulations, aiming to enhance communication within the healthcare system and between practitioners and institutions.

Question	Answer
Form Name	Mn Uniform Change Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	minnesota practitioner change, mn uniform practitioner change form, mn uniform practitioner change form bcbs, uniform change form

Form Preview Example

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

MINNESOTA UNIFORM PRACTITIONER CHANGE FORM – Revised March 2009

Add – Remove – Change Demographic Data for Credentialed Practitioners and Specialists Not Subject to Credentialing: ER Physician, Pathologist, Radiologist, Anesthesiologist, CRNA, Neonatologist, Dietitian, Therapists (PT;OT; SLP), Audiologist – check with entity if unsure

Demographic Verification and Authorization

Completed and authorized on behalf of the practitioner by:

Name:

Clinic Name:

Phone #:		FAX #:				E-Mail:
Signature:				Title:				Date:

Practitioner Demographic Information for this Request

Last:				First:			MI:	SSN:
Title:	MD	DO	DDS	Other				DOB:
				Title:
	DC	DPM	Ph.D					Female
	DC	DPM	Ph.D					Female
					Type I
DEA:			State:		NPI:	Medicaid ID:			State:

Male

License Number:

State:

Languages Spoken Fluently:

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO


ADD	REMOVE	Remove ALL sites for this TIN? YES NO	Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO

ADD

REMOVE

Remove ALL sites for this TIN? YES NO

Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO


ADD	REMOVE	Remove ALL sites for this TIN? YES NO	Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

CHANGE Practitioner Demographic Data

Old:		New:
Last Name:		Last Name:
First Name:	MI:	First Name:		MI:
Specialty:		Specialty:
License #:		License #:
	(Include State)			(Include State)
DEA #:		DEA #:
			(Please attach copy of NEW DEA Certificate to this form)
Type I NPI #:		Type I NPI #:
Effective Date of Change:

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

Primary Site? YES NO

Phone:

Zip:

Directory Suppress?

THE FOLLOWING SITE LOCATION ADDENDUM FORM IS USED IN CONJUNCTION WITH THE MINNESOTA UNIFORM PRACTITIONER CHANGE FORM WHEN ADDING OR REMOVING PRACTITIONERS FROM MORE THAN THREE SITES. THIS FORM WILL ONLY BE ACCEPTED WHEN IT IS ACCOMPANIED BY A COMPLETED MINNESOTA UNIFORM PRACTITIONER CHANGE FORM.

SITE LOCATION ADDENDUM

Must indicate if the additional site(s) are being ADDED or REMOVED

ADDITIONAL LOCATION(s) FOR:

Last:

First:

MI:

SSN:

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO


ADD	REMOVE	Remove ALL sites for this TIN? YES	NO	Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO

ADD

REMOVE

Remove ALL sites for this TIN? YES

Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO

ADD

REMOVE

Remove ALL sites for this TIN? YES

Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

ADD/REMOVE Practitioner

Clinic	Hospital	Clinic/Hospital Name:
Address:				City/State:

Tax ID:			Type 2 NPI for this site:
Tax ID:
Effective Date:			Practicing Specialty at this Site:

YES NO

ADD

REMOVE

Remove ALL sites for this TIN? YES

Remove Reason:

List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form.

Location addendum.doc – March 2009

Mn Uniform Change Form – Fill Out and Use This PDF

Mn Uniform Change Form PDF Details

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