Provider Information Update Form PDF Details

Maintaining an accurate provider directory is a cornerstone of Johns Hopkins Healthcare's commitment to quality service delivery. The Provider Information Update Form plays a pivotal role in this process, ensuring all provider data remains current and thereby, aiding in the seamless operation of healthcare services. Providers are required to notify Johns Hopkins Healthcare of any changes to their information at least thirty (30) days before such changes take effect. This notification can be done in writing or by submitting the specified form, complete with all the current details. Additionally, it's crucial for the providers to include their W-9 when submitting the completed form to the Provider Relations through the designated email address. It is important to highlight that if a Social Security Number is used instead of a Tax ID, the form has to be faxed for enhanced identity protection. The form accommodates various updates, including changes in provider name, specialty, panel status, or practice information such as name, Tax ID, NPI, and contact details. This systematic approach not only facilitates an up-to-date provider directory but also supports Johns Hopkins Healthcare's dedication to operational excellence and patient satisfaction.

QuestionAnswer
Form NameProvider Information Update Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprovider information update form, provider update form, florida bluecross provider form, provider information update

Form Preview Example

Provider Information Update Form

Email: ProviderChanges@jhhc.com

Questions? Call Provider Relations at 1-888-895-4998

Johns Hopkins Healthcare is dedicated to maintaining an accurate and up-to-date provider directory. Provider Information Change Notification must be made at least thirty (30) days in advance of the change in writing or using this form.

Complete this form with all current information. Send completed form along with your W-9 to Provider Relations via the above email address. PLEASE NOTE: IF USING A SOCIAL SECURITY # IN PLACE OF A TAX ID, THIS COMPLETED

UPDATE FORM MUST BE FAXED TO 410-424-4604 TO ENSURE IDENTITY PROTECTION.

Check here to indicate there are no changes at this time.

 

PRODUCT:

EHP

 

USFHP

PPMCO

 

 

 

 

Advantage MD

ElderPlus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TODAY’S DATE:

 

 

 

 

 

 

 

 

 

Effective Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of Change:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Information:

New

Change

Remove

 

If Change, select all that apply

Name

 

Specialty

Panel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type I NPI:

 

 

 

 

 

 

 

 

CAQH Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

Is Provider a Primary Care Physician:

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Specialty:

 

 

 

 

 

 

 

 

Board Certified in Specialty: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, attach copy of board certification

 

 

 

 

 

Panel Status:

Open Panel

Close Panel

 

 

 

 

 

Reason for Panel Change:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Leaving Practice: Moved Out of Area

 

Retired

Other:

 

 

 

 

 

 

 

 

Joining Another Practice

 

Deceased

 

 

 

 

 

 

 

Practice Information:

New

Change

Remove

Type of Change

Name

TAX ID

NPI

Email or Contact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practice Name:

 

 

 

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tax ID:

 

 

 

 

 

 

 

Type II NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

Contact’s Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Name:

 

 

 

 

 

 

 

New Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Tax ID:

 

 

 

 

 

 

 

New Type II NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Contact Name:

 

 

 

 

 

 

 

New Contact Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Information:

New

Change

Remove

 

Type of Location

Practice

Mailing/Corres.

Vendor/Billing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Information:

New

Change

Remove

 

Type of Location

Practice

Mailing/Corres.

Vendor/Billing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person authorized to make change (Print):

 

 

 

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Information Update Form, PNM. 008

Revised 5/12/2017

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florida medicaid provider update form New Specialty, Panel Status, Open Panel, Close Panel, Board Certified in Specialty If, Yes No, Provider Leaving Practice Moved, Retired Other, Joining Another Practice Deceased, Practice Information New, Change, Remove Type of Change Name, TAX ID NPI, Email or Contact, and Practice Name fields to insert

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