Get the free medicaid fee for service provider change of address form

INSTRUCTIONS FOR COMPLETING THE MEDICAID FEE FOR SERVICE PROVIDER CHANGE OF ADDRESS FORM General Instructions Pages 1 and 2 of the Change of Address Form must be returned. Red ink white out and double-sided forms are unacceptable. O. Box 4610 Rensselaer NY 12144-4610 Date// MEDICAID FEE FOR SERVICE PROVIDER CHANGE OF ADDRESS FORM Medicaid Provider Number Required National Provider Identifier Required unless NPI exempt Category of Service Provide...

How to fill out medicaid fee for service provider change of address form

How to fill out medicaid fee for service provider change of address form

1. Obtain the Medicaid Fee for Service Provider Change of Address Form from the official website or local Medicaid office.
2. Fill in the provider's name and Medicaid provider number at the top of the form.
3. Provide the current address of the provider in the designated section.
4. Enter the new address where services will be provided.
5. Ensure all sections of the form are completed accurately, including phone numbers and email addresses if required.
6. Sign and date the form to certify the information is correct.
7. Submit the completed form to the appropriate Medicaid office, following any specific submission guidelines they may have.

Who needs medicaid fee for service provider change of address form?

1. Healthcare providers who are enrolled in Medicaid and need to update their address.
2. Providers who may have moved their practice location or changed their mailing address.
3. Any Medicaid provider who wants to ensure that their payment and correspondence are sent to the correct address.

For pdfFiller’s FAQs

What is medicaid fee for service provider change of address form?

The Medicaid Fee for Service Provider Change of Address Form is a document used by healthcare providers to officially notify Medicaid of a change in their business address for billing and service purposes.

Who is required to file medicaid fee for service provider change of address form?

Healthcare providers participating in the Medicaid Fee for Service program are required to file this form when they change their address to ensure accurate billing and communication.

How to fill out medicaid fee for service provider change of address form?

To fill out the form, providers should include their current contact information, the new address, and any identifying details such as provider number or Tax ID. Accuracy is crucial to avoid disruptions in service.

What is the purpose of medicaid fee for service provider change of address form?

The purpose of the form is to maintain updated records with Medicaid, ensuring that claims are processed correctly and that providers receive timely communication and payments.

What information must be reported on medicaid fee for service provider change of address form?

The form must report the provider's current address, the new address, contact information, provider identification numbers, and any relevant dates to ensure a smooth transition.