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.

Here is the information relating to the file you were looking for to fill in. It will show you the time you will need to fill out provider information update form, ex

QuestionAnswer
Form NameProvider Information Update Form
Form Length1 pages
Fillable?Yes
Fillable fields73
Avg. time to fill out14 min 55 sec
Other namesflorida update form, medicaid nurse provider information florida, florida medicaid provider update form, update provider information sanford

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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