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PO Box 509001, San Diego, CA 92150-9001 PRACTITIONER STATUS CHANGE REQUEST CHANGING MAILING/BILLING ADDRESS This form should be used for: Changing Mailing address Changing Billing address Changing
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What is provider status change request?
Provider status change request is a formal request made by a healthcare provider to update their status or information with a regulatory body or insurance provider.
Who is required to file provider status change request?
Any healthcare provider who needs to update their status or information with a regulatory body or insurance provider.
How to fill out provider status change request?
Provider status change requests can typically be filled out online or through a designated form provided by the regulatory body or insurance provider.
What is the purpose of provider status change request?
The purpose of a provider status change request is to ensure that accurate and up-to-date information is on file for healthcare providers.
What information must be reported on provider status change request?
Provider status change request usually requires information such as personal details, contact information, credentials, and any changes being requested.
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