Provider Information Update Form PDF Details

The Provider Information Update Form is a new addition to the provider information collection process. The form was designed to help agencies more easily collect and track updates to Provider contact information. Providers are required to complete and submit the form whenever their contact information changes. Completing and submitting the form is quick and easy, and can be done online or through the mail. Agencies that use electronic health records will find it helpful in keeping provider contact information updated in their systems. Submitting the form helps agencies ensure that they have accurate contact information for all of their providers, which is important for both communication and billing purposes. For more information on the Provider Information Update Form, please visit our website or give us a call.

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QuestionAnswer
Form NameProvider Information Update Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow do i update my provider information on ahca, medicaid nurse provider information florida, florida provider update, provider information update form

Form Preview Example

MAIL TO: BLUE CROSS AND BLUE SHIELD OF FLORIDA

Provider Information Update Form

Use this form to update your provider information (e.g., service location, payment address, tax identification number) with Blue Cross and Blue Shield of Florida. Please complete all of Section I and only the information that is changing in Sections IIVIII. Providing complete and legible information will expedite your request and help ensure accurate processing. Mail or fax the completed form to the address and number indicated above.

Section I: Provider Information - Complete all fields below in Section I

Provider’s Full Name* (last, first, middle initial/business name)

Title

 

 

 

BCBSF Provider Number

Individual NPI

Organizational NPI

 

 

 

Medicare Number

Medical/DOH License Number

Social Security Number/Tax ID

 

 

 

 

Specialty

 

 

Effective Date of Request (MM/DD/YYYY)

 

 

 

Office Contact Name

Telephone Number (for appointments)

Email Address

 

(

)

 

 

 

 

 

*Legal documentation (e.g., marriage license) is required for changes to last name

Note: For Sections II–VIII, complete only the section(s) that requires a change.

Section II: Languages Spoken

List non-English languages spoken by provider and/or staff in order of fluency. (If language is spoken by staff only, please check “Staff” box.)

(1)Staff

(2)Staff

(3)Staff

Section III: Service Location

Please complete a separate form for each additional location.

Add new location

Relocated

Expire location

Correction to existing location

Previous

 

 

 

 

New

Office Location

 

Hospital Based Location

 

 

 

 

 

 

Other (independent diagnostic center, supplier, etc.)

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

Telephone Number

Fax Number

Telephone Number

Fax Number

(

)

(

 

)

 

(

)

(

 

)

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section IV: Office Hours

Office Hours

 

Mon

Tue

Wed

Thu

Fri

Sat

Sun

A.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

900-502-0511

May 2011

Section V: Payment/Billing Address

A signature at the bottom of this form by the Tax ID owner is required for all payment address changes.

Previous

 

 

 

New

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name (last, first, middle initial/business name)

Provider Name (last, first, middle initial/business name)

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

Telephone Number

Fax Number

 

Telephone Number

Fax Number

(

)

(

)

 

(

)

(

 

)

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section VI: Tax Identification/Employer Identification Number (TIN/EIN)

In order to update your Tax ID, a completed W-9 must be attached to this form.

Previous TIN/EIN

New TIN/EIN

Effective Date of Change

Section VII: Hospital Affiliation Update

A hospital privilege letter from the facility along with written notification from the provider’s office (administrator, manager, provider, etc.) and/or attestation form for hospital-based physicians is required.

Hospital Name

Hospital BCBSF

Hospital NPI

Add/Delete?

Effective/

Provider Number

Expiration Date

 

 

 

(1)

 

 

Add

 

 

 

Delete

 

 

 

 

 

 

 

 

 

 

(2)

 

 

Add

 

 

 

Delete

 

 

 

 

 

 

 

 

 

 

Section VIII: Professional Association Deletion

Group NPI

Effective Date of Group Disassociation Physician NPI

Print Name of

 

Signature of

Physician/Provider

 

Physician/Provider

Note: A Billing Authorization for Professional Associations (PA) Form must be completed when adding a provider to a group. A PA Form along with an attestation form is needed for hospital-based providers.

Additional Comments

Print Name ________________________________

Signature _____________________________________

Title ______________________________________

Date _________________________________________

900-502-0511

May 2011

For Internal Use Only: Provider Number ___________

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