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Provider / Practice Name, Address Here MEMBER AUTHORIZATION TO CHANGE PRIMARY CARE PRACTITIONER (PCP) CONFIDENTIAL FAX AND EMAIL Date: To: Molina Healthcare Member Services Email: MHNMEnrollment molinahealthcare.com
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How to fill out provider practice name address
How to fill out provider practice name address:
01
Start by writing the name of the provider's practice. This is typically the official name registered with relevant authorities.
02
Next, enter the complete address of the provider's practice, including street address, city, state, and zip code.
03
Make sure to include any additional address details, such as suite or building number, if applicable.
04
Double-check that the spelling and formatting of the practice name and address are accurate and consistent.
05
If required, provide any additional information requested, such as a P.O. Box number or department name.
06
Sign and date the form, as appropriate.
Who needs provider practice name address:
01
Healthcare providers: Doctors, dentists, chiropractors, psychologists, and other healthcare professionals must provide their practice name address for various administrative and regulatory purposes.
02
Insurance companies: When healthcare providers submit claims to insurance companies, they typically need to include their practice name address for payment processing and communication purposes.
03
Medical boards and licensing authorities: These entities often require healthcare providers to provide their practice name address when applying for or renewing their professional licenses.
04
Patients: Providing the practice name address allows patients to easily locate and contact their healthcare provider's office for appointments, inquiries, or other needs.
05
Government agencies: For certain purposes, government agencies may request the practice name address of healthcare providers, such as for compliance audits, inspections, or Medicare/Medicaid enrollment.
06
Business partners: In collaborative or contractual arrangements, other companies or organizations may need the practice name address of a healthcare provider for billing, communication, or legal purposes.
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What is provider practice name address?
The provider practice name address is the official name and physical location of the healthcare provider.
Who is required to file provider practice name address?
Healthcare providers are required to file their practice name address.
How to fill out provider practice name address?
You can fill out the provider practice name address by providing the official name of the practice and its physical location.
What is the purpose of provider practice name address?
The purpose of the provider practice name address is to accurately identify the healthcare provider and their location.
What information must be reported on provider practice name address?
The information that must be reported includes the official name of the practice and its physical address.
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