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Provider Demographic Updates: Ancillary

Ancillary

Back to primary service type selections

Please Select the Demographic Update Requested

Select all that apply. required * Address Update - Correspondence Address Address Update - Practice Location Address Address Update - W-9 Address Pay To Information - Update CLIA Update Contact Information - Office/Primary Contact Information Update Contact Information - Credentialing Contact Update Contract Entity Name Change Practitioner Name Change TAX ID Change Telephone of Fax Number Change Term Provider or Practitioner OTHER - Enter Specific Request in the Other box at the bottom of the form.

Error: Demographic Update Selection is required.

Please select Provider type required * ASC Dialysis DME FQHC Home Health Hospice Independent Laboratory/Pathology and/or Radiology RHC Transportation

Error: Provider Type is required.

Effective Date for updates:

Effective Date for Changes *

Error: Effective Date is required.

You have selected a contract entity name change AND tax ID change which will require a new contract. Please complete the Join Our Network applicable form. Our contracting team will contact you to initiate a new contract.

Please populate the below.

Provider Name *

Error: Provider Name is required.

NPI *

Error: NPI is required.

License Number *

Error: License Number is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

Line of Business (Please select all that apply) required * Medicaid Medicare Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Practice Location Address Update

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Directory Inclusion choice is required.

Additional Locations - Please list alternate and/or covering-only locations below. One practitioner can have up to 5 covering locations.

Number of addtional locations

Additional Location 1

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 2

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 3

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 4

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 5

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Correspondence Address

Contract Entity Name *

Error: Contract Entity Name is required.

Street Address *

Error: Correspondence Address is required.

City *

Error: Correspondence City is required.

State

Zip Code *

Error: Correspondence Zip Code is required.

County *

Error: Correspondence County is required.

Phone Number *

Error: Correspondence Phone Number is required.

Fax Number *

Error: Correspondence Fax Number is required.

Pay To Information

Pay To Name *

Error: Pay To Name is required.

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: State is required.

Zip Code *

Error: Pay To Zip Code is required.

W-9 Address

Legal Entity Name *

Error: W-9 Legal Entity Name is required.

Street Address *

Error: W-9 Address is required.

City *

Error: W-9 City is required.

State *

Error: W-9 State is required.

Zip Code *

Error: W-9 Zip Code is required.

Tax ID Change

Current TAX ID *

Error: Current TAX ID is required.

New TAX ID *

Error: New TAX ID is required.

New TAX ID Effective Date *

Error: New TAX ID Effective Date is required.

Provider Name Change

Current Ancillary Provider Name *

Error: Current Ancillary Provider Name is required.

NPI Number *

Error: NPI Number is required.

New Ancillary Provider Name *

Error: New Ancillary Provider Name is required.

NPI Number *

Error: NPI Number is required.

Effective Date of New Ancillary Provider Name *

Error: Effective Date of New Ancillary Provider Name is required.

Telephone or Fax Number Update

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Contract Entity Name Change

Current Contract Entity Name *

Error: Current Contract Entity Name is required.

New Contract Entity Name *

Error: New Contract Entity Name is required.

Effective Date *

Error: Effective Date is required.

CLIA Update

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Term Provider or Practitioner

Provider or Practitioner Name *

Error: Provider or Practitioner Name is required.

Term Status (Please select the applicable term status below) required * Complete Term/Inactivate Provider ID Term from Location (If Selected Address box pops up)

Error: Term Status is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

Term Reason *

Error: Term Reason is required.

Term Effective Date *

Error: Term Effective Date is required.

Select Line of Business required * Medicaid Medicare Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Group NPI *

Error: Group NPI is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Your Contact Information

Primary Contact Name *

Error: Primary Contact Name is required.

Email *

Error: Primary Contact Email is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Email *

Error: Credentialing Contact Email is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information

Other

Other (Specific Request)

Ancillary License - Reflecting New Name *

Error: Ancillary License upload is required.

Items in the trash will be permanently removed after 30 days.

CLIA Certificate *

Error: CLIA Certificate upload is required.

Items in the trash will be permanently removed after 30 days.

Updated W-9 Form *

Error: Updated W-9 Form upload is required.

Items in the trash will be permanently removed after 30 days.

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Error: Please add a Captcha.

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