Get the free Provider Account Change Form

Provider Account Change Form Provider Accounts & Credentialing PO Box 44261 Olympia WA 985044261For L&I Use Only Provider Account #Fax: 3609024484 Questions? Email PacMail@Lni.wa.gov1. Account Information

How to fill out provider account change form

How to fill out provider account change form

1. Obtain the provider account change form from the designated department or website.
2. Fill out the basic information section including name, contact information, and provider ID.
3. Indicate the changes you wish to make to your provider account such as address, phone number, or specialty.
4. Include any supporting documentation required for the change such as a copy of a new license or certification.
5. Sign and date the form to certify the accuracy of the information provided.
6. Submit the completed form to the appropriate department or contact person for processing.

Who needs provider account change form?

1. Healthcare providers who need to update or modify their account information such as address, contact details, or practice information.
2. Providers who have experienced a change in licensing, certification, or specialty and need to update their records.

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What is provider account change form?

The provider account change form is a document used to request updates or changes to an existing provider account, such as changes in address, contact information, or business structure.

Who is required to file provider account change form?

Providers who need to update their account information, including healthcare professionals, organizations, or businesses that render services, are required to file the provider account change form.

How to fill out provider account change form?

To fill out the provider account change form, one must provide accurate and complete information relevant to the account changes, including personal details, new address or contact information, and any other required documentation.

What is the purpose of provider account change form?

The purpose of the provider account change form is to officially document and facilitate any changes to a provider's account with the relevant authority, ensuring that all information is current and correctly processed.

What information must be reported on provider account change form?

The information that must be reported includes the provider's current account information, details of the changes being requested, new contact details, and any supporting documentation as required.