Provider Name Change
Items required for name change: License, DEA, CSR, Certificate of Insurance (COI), Collaborative Practice Agreement (CPA), 1500 claim form (blinded/voided), Legal Document supporting name change (marriage license, court document, etc.) driver’s license
Adding a Practice Location
Items required to add location Certificate of Insurance (new TINs), W9, 1500 claim form (blinded/voided), Collaborative Practice Agreement (CPA) if applicable