** IMPORTANT **
You must submit a W9 and sample CMS 1500 form for each location change or addition.
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
If adding a practice location, you must complete the "Add A Pay To/Remit To Location".
Add a Pay to/Remit to Location
Eliminate Practice Location
Change Practice Location
Change Pay to/Remit to Location