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This document serves as a guide for updating the legal name, Doing Business As (DBA) name, and address listed on a provider profile for IHCP. It includes instructions for form completion and relevant
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How to fill out ihcp provider name and
How to fill out IHCP Provider Name and Address Maintenance Form
01
Obtain the IHCP Provider Name and Address Maintenance Form from the official website or local office.
02
Fill in the provider's name in the designated section at the top of the form.
03
Provide the complete address including street, city, state, and zip code under the address section.
04
Include any relevant contact information such as phone numbers and email addresses.
05
Indicate any changes to the existing information if applicable.
06
Review the form for accuracy and completeness.
07
Sign and date the form where indicated.
08
Submit the form according to the provided instructions, either by mail or electronically.
Who needs IHCP Provider Name and Address Maintenance Form?
01
Any healthcare provider or organization that is enrolled in the Indiana Health Coverage Programs (IHCP) and needs to update their name or address information.
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What is IHCP Provider Name and Address Maintenance Form?
The IHCP Provider Name and Address Maintenance Form is a document used by healthcare providers to update or change their name and address information in the Indiana Health Coverage Program.
Who is required to file IHCP Provider Name and Address Maintenance Form?
Any healthcare provider enrolled in the Indiana Health Coverage Program who needs to update their name or address information is required to file this form.
How to fill out IHCP Provider Name and Address Maintenance Form?
To fill out the IHCP Provider Name and Address Maintenance Form, providers should follow the instructions provided on the form, ensuring that all required fields are completed accurately, including the current and new name and address information.
What is the purpose of IHCP Provider Name and Address Maintenance Form?
The purpose of the IHCP Provider Name and Address Maintenance Form is to ensure that the Indiana Health Coverage Program has accurate and up-to-date contact information for healthcare providers, which helps in communication and in processing claims.
What information must be reported on IHCP Provider Name and Address Maintenance Form?
The information that must be reported on the IHCP Provider Name and Address Maintenance Form includes the provider's current name, new name (if applicable), current address, new address, and any relevant identification numbers.
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