WA CHPW Clinic and Group Changes Form 2019-2025 free printable template

CLINIC AND GROUP CHANGES FORM Please complete the appropriate section of this form and email the completed form to: PROVIDER.CHANGES CHEW.ORG Please note: Incomplete information may result in a delay

How to fill out WA CHPW Clinic and Group Changes

How to fill out WA CHPW Clinic and Group Changes Form

1. Obtain the WA CHPW Clinic and Group Changes Form from the official website or your local office.
2. Fill in the clinic name and address at the top of the form.
3. Indicate the specific changes you are reporting, such as new services offered or changes to the staff.
4. Provide details about the group practices if applicable, including names and NPI numbers.
5. Check the box for the type of change (e.g., addition, deletion, update).
6. Sign and date the form at the bottom.
7. Submit the completed form to the designated CHPW contact via email or mail.

Who needs WA CHPW Clinic and Group Changes Form?

1. Healthcare providers or clinics that wish to report changes in their operational status.
2. Group practices that need to update their information with CHPW.
3. Organizations participating in the Washington Apple Health managed care program.

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What is WA CHPW Clinic and Group Changes Form?

The WA CHPW Clinic and Group Changes Form is a document used by healthcare providers in Washington to report changes in clinic or group information to Community Health Plan of Washington (CHPW).

Who is required to file WA CHPW Clinic and Group Changes Form?

Healthcare providers who are part of the CHPW network and need to update their clinic or group information are required to file the WA CHPW Clinic and Group Changes Form.

How to fill out WA CHPW Clinic and Group Changes Form?

To fill out the WA CHPW Clinic and Group Changes Form, providers must provide accurate and updated information regarding their clinic or group, ensure that all required fields are completed, and submit the form to CHPW as per their guidelines.

What is the purpose of WA CHPW Clinic and Group Changes Form?

The purpose of the WA CHPW Clinic and Group Changes Form is to keep CHPW up to date with any changes in clinic or group information to ensure proper communication and coordination of care.

What information must be reported on WA CHPW Clinic and Group Changes Form?

The information that must be reported includes the clinic's name, address, phone number, type of changes being made, contact person details, and any other relevant information that may affect the provider's participation in the CHPW network.