Get the free 9676-A Provider Demographic Change Form NENY.doc

PROVIDER DEMOGRAPHIC CHANGE FORM Bluesier of Northeastern New York PROVIDER ENROLLMENT DEPARTMENT 257 West Geneses Street Buffalo, NY 14202 CONFIDENTIAL Please complete all sections of this form;

How to fill out 9676-a provider demographic change

How to fill out 9676-a provider demographic change?

1. Gather the necessary information: Before filling out the form, gather all the relevant details that you need to provide accurate and up-to-date information. This may include your practice or organization name, address, contact information, and any changes you need to report.
2. Access the form: Obtain a copy of the 9676-a provider demographic change form. You can typically obtain this form from your local regulatory or governing body, or it may be available online on their official website.
3. Read the instructions: Take the time to carefully read the instructions provided with the form. These instructions will guide you through the process and ensure that you complete the form correctly.
4. Provide your identification details: Begin by filling in your identification details on the form. This may include your name, National Provider Identifier (NPI), tax identification number (TIN), and other relevant identifiers.
5. Specify the changes: Indicate the specific changes you need to report in the appropriate fields of the form. This may include updating your practice or organization address, contact information, legal entity information, or any other relevant information.
6. Attach supporting documentation: If required, attach any supporting documentation along with the form. This may be necessary to provide evidence or justification for the changes you are reporting.
7. Review and double-check: Before submitting the form, carefully review all the information you have provided. Double-check for any errors or omissions to ensure the form is filled out accurately.
8. Submit the form: Once you have completed the form and reviewed it, submit it to the appropriate regulatory or governing body as instructed. Follow any additional submission guidelines or requirements to ensure your form is processed correctly.

Who needs 9676-a provider demographic change?

1. Healthcare providers: Individual healthcare providers who have undergone changes in their practice or organization details such as address, contact information, or legal entity information may need to fill out the 9676-a provider demographic change form.
2. Medical practices: Medical practices, clinics, or healthcare organizations that have experienced changes in their demographics, such as relocation or restructuring, may also require the completion of the 9676-a form.
3. Insurance providers: Insurance providers and payers may request healthcare providers to update their demographic information using the 9676-a form, ensuring accurate network directory listings and claims processing.
4. Regulatory bodies: Regulatory bodies or governing authorities responsible for overseeing healthcare provider information may require the submission of the 9676-a form to maintain accurate provider databases and ensure compliance with regulations.

Please note that the specific requirements for completing the 9676-a provider demographic change form may vary depending on your location and the regulations or policies in your jurisdiction.

For pdfFiller’s FAQs

What is 9676-a provider demographic change?

9676-a provider demographic change refers to a form used to update information about a healthcare provider.

Who is required to file 9676-a provider demographic change?

Healthcare providers who have changes in their demographic information are required to file 9676-a provider demographic change.

How to fill out 9676-a provider demographic change?

To fill out 9676-a provider demographic change, healthcare providers need to provide accurate and up-to-date information about their demographics.

What is the purpose of 9676-a provider demographic change?

The purpose of 9676-a provider demographic change is to ensure that healthcare provider information is current and accurate.

What information must be reported on 9676-a provider demographic change?

Information such as name, address, contact information, and any other relevant demographic details must be reported on 9676-a provider demographic change.

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