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Provider Demographic Updates: Pharmacist

Pharmacist - Ambetter Only

Back to primary service type selections

Please Select the Demographic Update Requested

Select all that apply. required * Address Update - Correspondence Address Address Update - Pay to Address Address Update - Practice Location Address Address Update - W-9 Address CLIA Update Contact Information - Credentialing Contact Update Contact Information - Office/Primary Contact Information Update Group Name Change Pharmacist CE Status Update - Ambetter Only Pharmacist Board Certified Protocol Status Update - Ambetter Only Provider/Practitioner Name Change TAX ID Change Telephone Number Change 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 * Solo Practice Group Practice

Error: Provider Type is required.

Administration of Medications, Biologics, and Vaccines

Administration of Medications, Biologics, and Vaccines required * Yes (if Yes, attach the CE Certification Certificate) No

Error: Administration of Medications, Biologics, and Vaccines is required.

Attach CE Certification Certificate

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

Board Certified Protocols

Please select identify all Board Certified Protocols that the provider has attestation. (Select All That Apply) required * Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol v5 Acute Influenza Infection: Antiviral Therapy Protocol Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy Colorectal Cancer (Crc) Screening Protocol Acute, Uncomplicated Urinary Tract Infection Treatment Protocol Tuberculin Skin Testing Two-Step Protocol: For initial testing in adults who will be undergoing annual testing Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy

Error: Board Certified Protocol is required.

Please attach all attestations for each Board Certified Protocol selected.

Attach attestation for: Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol *

Error: Form upload is required.

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

Attach attestation for: Acute Influenza Infection: Antiviral Therapy Protocol *

Error: Form upload is required.

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

Attach attestation for: Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy *

Error: Form upload is required.

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

Attach attestation for: Colorectal Cancer (Crc) Screening Protocol *

Error: Form upload is required.

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

Attach attestation for: Acute, Uncomplicated Urinary Tract Infection Treatment Protocol *

Error: Form upload is required.

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

Attach attestation for: Tuberculin Skin Testing Two-Step Protocol *

Error: Form upload is required.

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

Attach attestation for: Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy *

Error: Form upload is required.

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

Please populate the below.

Provider/Practitioner Name *

Error: Provider Name is required.

CAHD ID # *

Error: CAHD Number is required.

License Number *

Error: License Number is required.

NPI *

Error: NPI 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.

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.

Correspondence Address

Correspondence Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Correspondence Address is required.

City *

Error: Correspondence City is required.

State *

Error: Correspondence State is required.

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.

CLIA Number *

Error: Correspondence CLIA Number is required.

CLIA Expiration *

Error: Correspondence CLIA Expiration is required.

Pay To Address

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: Pay To 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.

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 (Specific Request)

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