Deaconess Health Plans / For Providers / Provider Update Form (PUF)

Provider Update Form

** IMPORTANT ** You must submit a W9 and sample CMS 1500 form for each location change or addition.

Submitter Information

Person Completing Form:

Phone:

Email:

Provider Identification

Provider's First Name:

MI:

Last Name:

Degree:

Provider's Individual NPI:

Provider Name Change

Previous Name:

New Name:

Reason for 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

Terminating a Provider

Termination Date:

TIN(s):

Reason for termination:

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

Practice Name:

Practice Group NPI:

Tax ID:

Street:

City:

State:

ZIP:

County:

Phone:

Fax:

Office Manager/Contact:

Email:

Is this the primary location for provider?:

YesNo

Effective Date:

List location in provider directory? (Only locations where patients are routinely seen should be listed in directory.):

YesNo

Specialty Practiced at this Location:

If adding a practice location, you must complete the "Add A Pay To/Remit To Location".

Add a Pay to/Remit to Location

Pay to/Remit to Name:

Street:

City:

State:

ZIP:

Phone:

FAX:

Billing Manager/Contact:

Email:

Effective Date:

Eliminate Practice Location

Practice Name:

Practice Group NPI:

Street:

City:

State:

ZIP:

TIN:

Effective Date:

Change Practice Location

Old Practice Name:

New Practice Name:

Old Practice Tax ID:

New Practice Tax ID:

Old Practice Group NPI:

New Practice Group 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:

Additional Information

Comments:

Attachment:

ATTACH FILE

A single document can be attached to this request. You can combine all of the documents required into a single pdf file or create a zip file. If you do not wish to attach, the documents can be faxed to 812-450-2030.