Anthem Professional Individual/Professional Group Change Request Form 2016-2025 free printable template

Professional Individual/Professional Group Change Request Form Dear Provider/Office Manager: As you know it is critical that your patients/our m embers receive accurate and current data related to

How to fill out Anformm Professional IndividualProfessional Group Change Request

How to fill out Anthem Professional Individual/Professional Group Change Request Form

1. Obtain the Anthem Professional Individual/Professional Group Change Request Form from the Anthem website or your local office.
2. Fill out the provider information section, including your name, NPI number, and practice address.
3. Indicate whether you are submitting a change request for an individual or group.
4. Provide details of the changes you are requesting, such as updates to your contact information or changes in practice location.
5. Confirm that all information is accurate and complete before submission.
6. Sign and date the form to certify the contents are true.
7. Submit the completed form via the specified method (fax, email, or mail) as indicated in the form instructions.

Who needs Anthem Professional Individual/Professional Group Change Request Form?

1. Healthcare providers who need to update their information with Anthem, such as changes in practice location, contact information, or ownership.
2. Group practices that need to modify their group details or make changes regarding providers within the group.
3. Any current Anthem provider that requires updates to their existing professional group or individual provider information.

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What is Anthem Professional Individual/Professional Group Change Request Form?

The Anthem Professional Individual/Professional Group Change Request Form is a document used to request changes related to professional services with Anthem, covering individual or group practice adjustments.

Who is required to file Anthem Professional Individual/Professional Group Change Request Form?

Providers who wish to make changes to their professional status, such as updates to their practice location, provider information, or group affiliation, are required to file this form.

How to fill out Anthem Professional Individual/Professional Group Change Request Form?

To fill out the form, accurately provide all requested information, including personal details, practice information, and the specific changes being requested. Ensure all sections are completed and submit the form as per the provided instructions.

What is the purpose of Anthem Professional Individual/Professional Group Change Request Form?

The purpose of this form is to facilitate the process of updating and managing provider information with Anthem, ensuring that records are accurate and up-to-date for billing and patient care.

What information must be reported on Anthem Professional Individual/Professional Group Change Request Form?

The form requires completion of information such as provider name, National Provider Identifier (NPI), practice address, contact information, and specific details regarding the changes being requested.