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Provider Demographic Updates

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 - 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 Pharmacist CE Status Update - Ambetter Only Pharmacist Board Certified Protocol Status Update - Ambetter Only 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.

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.

Effective Date for Updates: (Please enter the effective date for the requested updates)

Effective Date for Changes *

Error: Effective Date 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) 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/Practitioner Name is required.

CAHD ID # *

Error: CAHD ID # 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.

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.

Primary Location required * Yes No

Error: Primary Location is required.

Covering Location required * Yes No

Error: Covering Location 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.

Practitioner Name Change

Current Pharmacist Name *

Error: Current Pharmacist Name is required.

NPI Number *

Error: NPI Number is required.

New Pharmacist Name *

Error: New Pharmacist Name is required.

NPI Number *

Error: NPI Number 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

Pharmacy Location Name *

Error: Pharmacy 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.

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.

Term Effective Date *

Error: Term Effective Date 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)

Please attach the documents listed below. * Attachments required for submission.

Pharmacist License - Reflecting New Name *

Error: Pharmacist 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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