Provider Information Update Form – Fill Out and Use This PDF

Provider Information Update Form is a document that allows you to update your provider information.

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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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Question	Answer
Form Name	Provider Information Update Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	provider information update form, provider update form, florida bluecross provider form, provider information update

12

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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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This PDF editor enables you to fill in forms. You should not undertake much to update florida bluecross provider form documents. Merely adhere to these actions.

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florida medicaid provider update form empty fields to consider

Fill out the 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 section with all the details asked by the platform.

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

In the Authorized Signature, Person authorized to make change, Signature, Email, Title, Date, Provider Information Update Form, and Revised area, identify the key details.

Entering details in florida medicaid provider update form part 3

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