Deaconess - Deaconess Health Plans - For Providers -Provider Update Request

Submitter Information

Person Completing Form:

Phone:

Email:

Provider Identification

Provider's First Name:

MI:

Last Name:

Title:

Provider's Individual NPI:

Provider's Group NPI:

Terminating a Provider

Termination Date:

TIN(s):

Did provider move out of area?:

YesNo

If yes, where?:

Did provider retire?:

YesNo

Adding a Practice Location

Practice Name:

Tax ID:

Street:

City:

State:

ZIP:

County:

Send Correspondence to this address?:

YesNo

Phone:

Fax:

Office Manager/Contact:

Email:

Is this the primary location for provider?:

YesNo

Effective Date:

List location in provider directory?:

YesNo

* Must complete the "Add A Pay To/Remit To Location".

Add a Pay to/Remit to Location

Pay to/Remit to Name:

Tax ID:

Street:

City:

State:

ZIP:

Send Correspondence to this address?:

YesNo

Phone:

FAX:

Billing Manager/Contact:

Email:

Eliminate Practice Location

Practice Name:

Effective Date:

Street:

City:

State:

ZIP:

Deactivate TIN:

Effective Date:

Change Practice Location

Old Practice Name:

New Practice Name:

Old Practice Tax ID:

New Practice Tax ID:

Old Practice NPI:

New Practice NPI:

Old Practice Street:

New Practice Street:

Old Practice City:

New Practice City:

Old Practice State:

New Practice State:

Old Practice ZIP:

New Practice ZIP:

Old Practice Manager:

New Practice Manager:

Old Practice Email:

New Practice Email:

Old Practice Phone:

New Practice Phone:

Old Practice Fax Number:

New Practice Fax Number:

Effective Date:

Change Pay to/Remit to Location

Old Pay/Remit Name:

New Pay/Remit Name:

Old Pay/Remit Tax ID:

New Pay/Remit Tax ID:

Old Pay/Remit NPI:

New Pay/Remit NPI:

Old Pay/Remit Street:

New Pay/Remit Street:

Old Pay/Remit City:

New Pay/Remit City:

Old Pay/Remit State:

New Pay/Remit State:

Old Pay/Remit ZIP:

New Pay/Remit ZIP:

Old Billing Manager/Contact:

New Billing Manager/Contact:

Old Pay/Remit Email:

New Pay/Remit Email:

Old Pay/Remit Phone:

New Pay/Remit Phone:

Effective Date:

Addition or Change in Misc. Provider Information

Additional Board Certification:

Effective Date:

Expiration Date:

Change in Provider Primary Specialty:

List this specialty in the directory:

YesNo

Change in Provider Secondary Specialty:

List this specialty in the directory:

YesNo

Change in Provider Practicing Specialty:

Provider Role:

PCPSpecialistBothN/A

PCP:

Specialty:

Addition or Change in Hospital Privileges

Additional Hospital Affiliation:

Effective Date:

Delete Hospital Affiliation:

Effective Date:

Accepting New Patients:

YesNo

Call Coverage Name(s):

Additional Information

Comments:

Provider Update Form

Submitter Information

Provider Identification

Terminating a Provider

Adding a Practice Location

Add a Pay to/Remit to Location

Eliminate Practice Location

Change Practice Location

Change Pay to/Remit to Location

Addition or Change in Misc. Provider Information

Addition or Change in Hospital Privileges

Additional Information