PROVIDERS
Provider/Practice/Site Change Form - Allied Health/Ancillary

In order to expedite claim processing, please complete this form whenever there are any changes to the following information.
Practice/Business Information
 
Site ID:  
   
Allied Health-Type: Ancillary-Type:
       
Special Needs Provider? Yes No
       
Type of Practices: Solo Partnership Corp. Ancillary Other
       
Practice Name:
       
Address:
       
City: State:
       
Zip:    
       
Phone: Fax:
       
Contact Person: Title:
       
Handicapped Accessible? Yes No
 
Foreign Language(s):
(Hold down the Ctrl key to select multiple languages)
       
Hospital Affiliations:
Primary:
Secondary:
Other:
       
Practice Associates/Affiliate Companies and their Specialties:
Board Certified? Yes No
Board Certified? Yes No
Board Certified? Yes No
       
Tax Identification Number:
If you are submitting a change regarding your Tax Identification Number, please remember to mail in a copy of your W-9 within 5 to 7 business days or your change will not be processed.
       
Office Hours
 
Monday: A.M P.M. After Hours Phone:
Tuesday: A.M P.M.    
Wednesday: A.M P.M.    
Thursday: A.M P.M.    
Friday: A.M P.M.    
Saturday: A.M P.M.    
Sunday: A.M P.M.    
       
Does Provider(s) participate with fee for service? Yes No
Does Provider(s) participate with Medicare? Yes No
Age Range:    
If Pediatric office, do you participate in Vaccines for Children Program? Yes No
       
Covering Physicians
       
Name: Phone:
Name: Phone:
       
Vendor Information
       
Check here if same as primary address If not, please complete the following:
 
Billing Name:
       
Address:
       
City: State:
       
Zip:    
       
Phone: Fax:
       
Contact Person:
       
To validate your request, please indicate your Name, Title and Date before submitting the completed form.
Submitted by:
Title:
Date: (ex: dd/mm/yyyy)
       
215-991-4350 • Provider Helpline • 1-888-991-9023
 
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