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A form to update the legal name, service location, or taxpayer identification number of a contracting entity with the CHP+ State Managed Care Network.
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How to fill out provider address change form
How to fill out Provider Address Change Form
01
Obtain the Provider Address Change Form from the relevant healthcare authority or website.
02
Fill in the provider's current information, including name, license number, and existing address.
03
Enter the new address details accurately, ensuring no errors in street number, street name, city, state, and zip code.
04
Provide any additional required information, such as contact numbers or email addresses.
05
Sign and date the form to confirm the accuracy of the information provided.
06
Submit the completed form through the designated submission method, whether by mail, fax, or online.
Who needs Provider Address Change Form?
01
Healthcare providers who are changing their practice location.
02
Medical professionals relocating their offices.
03
Organizations and facilities that require an address update for compliance.
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What is Provider Address Change Form?
The Provider Address Change Form is a document that healthcare providers use to officially notify relevant authorities or organizations about a change in their practice address.
Who is required to file Provider Address Change Form?
Healthcare providers who change their practice address are required to file the Provider Address Change Form to ensure that their records are up to date.
How to fill out Provider Address Change Form?
To fill out the Provider Address Change Form, providers need to include their current address, the new address, and other relevant identifying information, then submit the form to the appropriate regulatory or administrative body.
What is the purpose of Provider Address Change Form?
The purpose of the Provider Address Change Form is to maintain accurate and up-to-date records of healthcare provider locations for communication, compliance, and billing purposes.
What information must be reported on Provider Address Change Form?
The information that must be reported includes the provider's current address, new address, provider identification numbers, and any other relevant contact information.
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