Get the free Provider Change of Address Form TDBrv - Office of Group Benefits - groupbenefits
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Provider Change of Address Form Provider/Group Name: Date: Tax ID Number: Physical Address Billing Address Contract Mailing Address ***Must list a PHYSICAL address/location No Change Contact Person:
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What is provider change of address?
Provider change of address refers to the process of updating and notifying the appropriate authorities about a change in address for a healthcare provider.
Who is required to file provider change of address?
Healthcare providers, such as hospitals, clinics, and individual practitioners, are required to file a provider change of address when they move or change their primary practice location.
How to fill out provider change of address?
To fill out provider change of address, the healthcare provider needs to complete the designated form provided by the relevant regulatory or licensing authority. The form typically requires providing details such as the old and new address, contact information, and any additional required information.
What is the purpose of provider change of address?
The purpose of provider change of address is to ensure accurate and up-to-date information about healthcare providers' locations. This helps in maintaining the integrity of healthcare services, facilitating patient communication, and enabling appropriate regulatory oversight.
What information must be reported on provider change of address?
On provider change of address, healthcare providers typically need to report their old and new address, contact information, healthcare license or registration details, and any other information specified by the regulatory authority.
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