Provider Update Form

Your email address: *

please enter a valid email

Please choose the appropriate change to be made: *

Adding a new Location

New Office Location Information

Practice /Group Legal Name:*

Practice Name d/b/a (or directory listing):*

Office Address:*

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

County:*

Phone:*

Invalid Phone Number

Fax:

Invalid Fax Number

Tax ID: *

Is This Location a Federally Qualified Health Center, Rural Health Clinic, or an Indian Health Service : *

FQHC RHC IHS Not Applicable

Correspondence Address ( If same as above, click here )

Correspondence Address:

Suite #:

City:

State:

Zip:

please enter a valid zip

Phone:

Invalid Phone Number

Fax:

Invalid Fax Number

Providers At Location (1st Provider is Required)

1

Provider(s) Name/title at Location:*

Primary Office:*

Taxonomy:*

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:*

2

Provider(s) Name/title at Location:

Primary Office:

Taxonomy:

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:

3

Provider(s) Name/title at Location:

Primary Office:

Taxonomy:

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:

*If there are additional providers at this location, please submit a roster list separately with all applicable information above

Pay to Location

Pay To Name:*

Address:*

City:*

State:*

Zip:*

please enter a valid zip

Phone:*

Invalid Phone Number

Fax:

Invalid Fax Number

Group/ Billing NPI: *

Contact Person:*

Email: *

please enter a valid email

Office Details

Is this location Handicap Accessible?*

Are you accepting new patients? *New providers must choose yes.

Do you have age limitations to patient care? *

If yes, what age patients do you see? * List the age range.

Is there a system for 24/7 on call availability at this location?*

Are other languages other than English spoken in this office? *

If yes, please list languages (other than English). *

Is the contracted entity (at this location) affiliated with a separate optical: store/retailer/chain? *

If yes, provide Optical name.*

Office Hours

Sun*

To*

Mon*

To*

Tues*

To*

Wed*

To*

Thur*

To*

Fri*

To*

Sat*

To*

Services provided by this Entity/Location (at least one required)

Routine Exam Glasses Medical/Surgical Contact Lenses

Other Services

A Facility (Nursing Home,Assisted Living...) Group Homes Prison Schools Private Residence Services performed out of mobile unit(van/rv)

Other, Please specify:

Requested Effective Date:*

please enter a valid date

Office Closing

Requestor's Contact Information:

Requested By: *

Requestor's Phone Number: *

Invalid Phone Number

Requestor's Fax Number:

Invalid Fax Number

Office and Provider Information:

Office Name: *

Office Closing Address: *

City:*

State:*

Zip:*

please enter a valid zip

Tax ID: *

Office Closing Date:*

please enter a valid date

*I understand this location will be updated as closed for all providers with this Tax ID

Billing and/or Mailing Address Change

Please indicate which address should be changed by checking the applicable box below

Change existing mailing address

Change existing billing address-Updated W-9 required

Change both existing mailing/billing address-Updated W-9 required

Check box if this update applies to all providers under this TIN

Requested By: *

Requestor's Phone Number: *

Invalid Phone Number

Requestor's Fax Number:

Invalid Fax Number

Provider(s) Name Affected by Change: *

Provider(s) NPI: *

Provider(s) Tax ID: *

Office/Group Name: *

Old Mailing Address: *

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

New Mailing Address: *

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

Phone Number: *

Invalid Phone Number

Fax Number:

Invalid Fax Number

Old Billing Address: *

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

(if Billing Address is the Same as Mailing Address, Click here )

New Billing Address: *

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

Phone Number: *

Invalid Phone Number

Fax Number:

Invalid Fax Number

Effective Date Of Change:*

*must be Greater than or equal to today's date*

please enter a valid date

Adding Providers

New Provider Information

Practice /Group Legal Name:*

Practice Name d/b/a (or directory listing):*

Office Address:*

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

County:*

Phone:*

Invalid Phone Number

Fax:

Invalid Fax Number

Tax ID: *

Is This Location a Federally Qualified Health Center, Rural Health Clinic, or an Indian Health Service : *

FQHC RHC IHS Not Applicable

Correspondence Address (If same as above, click here )

Correspondence Address:

Suite #:

City:

State:

Zip:

please enter a valid zip

Phone:

Invalid Phone Number

Fax:

Invalid Fax Number

Providers At Location (1st Provider is Required)

1

Provider(s) Name/title at Location:*

Primary Office:*

Taxonomy:*

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:*

2

Provider(s) Name/title at Location:

Primary Office:

Taxonomy:

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:

3

Provider(s) Name/title at Location:

Primary Office:

Taxonomy:

Medicare ID #:

Medicaid ID #:

CAQH ID:

DOB:

please enter a valid date

NPI #:

*If there are additional providers at this location, please submit a roster list separately with all applicable information above

Pay to Location

Pay To Name:*

Address:*

City:*

State:*

Zip:*

please enter a valid zip

Phone:*

Invalid Phone Number

Fax:

Invalid Fax Number

Group/ Billing NPI: *

Contact Person:*

Email: *

please enter a valid email

Office Details

Is this location Handicap Accessible?*

Are you accepting new patients? * New providers must choose yes.

Do you have age limitations to patient care? *

If yes, what age patients do you see? * List the age range.

Is there a system for 24/7 on call availability at this location?*

Are other languages other than English spoken in this office? *

If yes, please list languages (other than English).*

Is the contracted entity (at this location) affiliated with a separate optical: store/retailer/chain? *

If yes, provide Optical name.*

Office Hours

Sun*

To*

Mon*

To*

Tues*

To*

Wed*

To*

Thur*

To*

Fri*

To*

Sat*

To*

Services provided by this Entity/Location (at least one required)

Routine Exam Glasses Medical/Surgical Contact Lenses

Other Services

A Facility (Nursing Home,Assisted Living...) Group Homes Prison Schools Private Residence Services performed out of mobile unit(van/rv)

Other, Please specify:

Requested Effective Date:*

please enter a valid date

Updating Practice Information

Updated Practice Information

Practice /Group Legal Name:*

Practice Name d/b/a (or directory listing):*

Office Address:*

Suite #:

City:*

State:*

Zip:*

please enter a valid zip

County:*

Phone:

Invalid Phone Number

Fax:

Invalid Fax Number

Tax ID: *

Is This Location a Federally Qualified Health Center, Rural Health Clinic, or an Indian Health Service :

FQHC RHC IHS Not Applicable

Office Details

Is this location Handicap Accessible?

Are you accepting new patients? New providers must choose yes.

Do you have age limitations to patient care?

If yes, what age patients do you see? List the age range.

Is there a system for 24/7 on call availability at this location?

Are other languages other than English spoken in this office?

If yes, please list languages (other than English):

Is the Contracted Entity (at this location) affiliated with a separate Optical:store/retailer/chain?

If yes, provide Optical name.

Office Hours

Sun

Mon

Tues

Wed

Thur

Fri

Sat

Services provided by this Entity/Location

Routine Exam Glasses Medical/Surgical Contact Lenses

Other Services

A Facility (Nursing Home,Assisted Living...) Group Homes Prison Schools Private Residence Services performed out of mobile unit(van/rv)

Other, Please specify:

Change Notes (250 Characters Max):*

Attach W9 and any additional supporting documents: