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PROVIDER UPDATE FORM
Use this form to tell us about any new information or changes to your current practice or payment structure.
You can email this completed form to Provider. RelationsWest@premera.com
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How to fill out contracted provider information change
How to fill out contracted provider information change
01
First, obtain the contracted provider information change form from the relevant authority or organization.
02
Next, carefully read the instructions on the form to understand the required information and any supporting documents.
03
Fill out the form accurately, providing the necessary details such as the provider's name, contact information, and any updated credentials.
04
Attach any required supporting documents, such as a copy of the provider's license or certification.
05
Review the completed form and supporting documents to ensure all necessary information has been provided.
06
Submit the form and supporting documents to the designated authority or organization either by mail, email, or online portal, as specified in the instructions.
07
Wait for confirmation or acknowledgement from the authority or organization regarding the status of the contracted provider information change.
08
If additional information or documents are requested, promptly provide them to complete the process.
Who needs contracted provider information change?
01
Any individual or organization that has experienced changes in their contracted provider information, such as a change in name, contact details, or credentials, would need to fill out a contracted provider information change form.
02
This could include healthcare providers, service providers, contractors, consultants, or any other entity that has a formal agreement or contract with an organization or authority.
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What is contracted provider information change?
Contracted provider information change is a process of updating and modifying the information of a contracted provider.
Who is required to file contracted provider information change?
The contracted provider or their authorized representative is required to file the contracted provider information change.
How to fill out contracted provider information change?
Contracted provider information change can be filled out by completing the necessary forms provided by the relevant authority and submitting them with the updated information.
What is the purpose of contracted provider information change?
The purpose of contracted provider information change is to ensure that accurate and up-to-date information about the contracted provider is available to the relevant parties.
What information must be reported on contracted provider information change?
The information that must be reported on contracted provider information change includes any changes in contact details, services offered, address, ownership, or any other relevant details.
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