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Provider Demographic Updates

Behavioral Health Facility

Back to primary service type selections

Please Select the Demographic Update Requested

Select all that apply. required * Address Update - Correspondence 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 or Facility 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.

You have selected a Tax ID change which will require a new contract or amendment. Please complete the Join Our Network applicable form. Please include the details of the Tax ID change in the "Please provide any additional information" section, including both the previous Tax ID and the new Tax ID. If the change also involves a legal entity name change, please include the former and updated entity names as well.

Effective Date for Updates:

Please enter the effective date for the requested updates. *

Error: Effective Date is required.

Please select Group Provider type required * BHSO - Behavioral Health Service Organization CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center CCBHC - Certified Community Behavioral Health Clinic Independent BH Provider Residential Crisis Stabilization Unit

Error: Group Provider is required.

Is the facility ASAM Certified? required * Yes No

Error: Group Provider is required.

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.

Are 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.

Primary Location required * Yes No

Error: Primary Location 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.

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.

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.

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.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration 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

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.

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.

Group NPI *

Error: Group NPI is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Contract Entity or Facility Name Change

Current Contract Entity/Facility Name *

Error: Current Contract Entity Name is required.

Current Contract Entity/Facility NPI Number

Current Contract Entity/Facility Tax ID *

Error: Current Contract Entity Tax ID is required.

New Contract Entity/Facility Name *

Error: New Contract Entity Name is required.

New Contract Entity/Facility NPI Number

New Contract Entity/Facility Tax ID *

Error: New Contract Entity Tax ID 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.

To better assist you, please restate your request and provide supporting information to confirm your request. *

Error: This field is required.

Other

Other (Specific Request) *

Error: This field is required.

Please attach Specific Request Documentation

Document 1