Get the free Practice Location Change Form - lsbd

Este formulario debe ser completado por los dentistas para notificar a la Junta Estatal de Odontología de Luisiana sobre cualquier cambio en la(s) dirección(es) de su(s) práctica(s).

How to fill out practice location change form

How to fill out Practice Location Change Form

1. Obtain the Practice Location Change Form from your healthcare organization or regulatory body.
2. Fill out personal information including your name, contact details, and identification number.
3. Provide details of your current practice location including address and contact information.
4. Specify the new practice location with the complete address and any relevant contact information.
5. Indicate the effective date of the change of location.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed form to the appropriate department as instructed, either online or via post.

Who needs Practice Location Change Form?

1. Healthcare professionals relocating their practice.
2. Doctors and practitioners changing their work address.
3. Any licensed individual whose practice location is changing and needs to keep records updated.

For pdfFiller’s FAQs

What is Practice Location Change Form?

The Practice Location Change Form is a document used by healthcare providers to officially notify relevant authorities or insurance companies of a change in the location where they provide services.

Who is required to file Practice Location Change Form?

Healthcare providers, including physicians and other practitioners, who change their practice location are typically required to file a Practice Location Change Form.

How to fill out Practice Location Change Form?

To fill out the Practice Location Change Form, providers should enter their current and new practice addresses, update contact information, and provide any necessary supporting documentation as required by the relevant authority or insurance company.

What is the purpose of Practice Location Change Form?

The purpose of the Practice Location Change Form is to ensure that patient records, billing, and communication are directed to the correct and updated practice location, maintaining compliance with regulations.

What information must be reported on Practice Location Change Form?

The information that must be reported typically includes the provider's name, old and new practice addresses, phone numbers, and any relevant identification numbers associated with their practice.