Get the free Provider Change of Address Form - Mississippi Medicaid
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2017 Positron Emission Tomography (PET) Services Survey
Part A : General Information1. Identification:Facility Name:
County:
Street Address:
City:
Zip:
Mailing Address:
Mailing City:
Mailing Zip:
Medicaid
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How to fill out provider change of address
How to fill out provider change of address
01
Obtain the provider change of address form from the relevant authority or download it from their website.
02
Fill out the form with accurate and up-to-date information.
03
Provide your existing provider information, including name and address.
04
Enter the new address or contact details that you want to update.
05
Include any supporting documentation required by the authority.
06
Review the completed form for accuracy and make sure all required information is provided.
07
Sign and date the form.
08
Submit the form to the designated authority through mail, online submission, or in-person.
09
Keep a copy of the submitted form for your records.
10
Follow up with the authority to ensure the change of address has been processed.
Who needs provider change of address?
01
Anyone who is a provider and needs to update their address or contact details with a relevant authority.
02
This is typically required by professionals such as doctors, lawyers, accountants, or business owners who have changed their practice location or contact information.
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What is provider change of address?
Provider change of address is a process whereby a healthcare provider updates their contact information, such as their physical address, phone number, or email address.
Who is required to file provider change of address?
All healthcare providers who have changed their contact information are required to file a provider change of address.
How to fill out provider change of address?
To fill out a provider change of address, a healthcare provider typically needs to submit a form or update their information online through the relevant healthcare authority.
What is the purpose of provider change of address?
The purpose of provider change of address is to ensure that healthcare providers can be easily contacted by patients, other providers, and healthcare authorities.
What information must be reported on provider change of address?
Healthcare providers must report their new physical address, phone number, and email address when filing a provider change of address.
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