ADDENDUM "G"
Practice or Facility Name Contact Person
Street Address and Suite Number
Contact Person's Telephone and Extension
City
State Zip Code
Contact Person's company issued email address
Provider Group Name
Type 2 NPI(s)
Provider Enrollment and Change Self-Service Access Request
Name
(Type or Print Full Name of Each User)
Telephone Number
Provider Secured Services
ID
Provider Enrollment and
Change Self-Service
Basic Access
Provider Enrollment and
Change Self-Service
Full Access
John Doe
111-222-3333 F000000
Provider Enrollment and Change Self-Service Authorization
By signing below, I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority
to enter into and bind my provider group to agreements. I understand, acknowledge, and attest that the user(s) listed on this Addendum have the authority to
perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the
Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals.
Note: This is an Addendum to the Provider Secured Services Use and Protection Agreement and does not alter the terms set forth therein.
Name of Authorized Group Representative Title of Authorized Group Representative
Signature of Authorized Group Representative
Handwritten signature only
Date
Please complete electronically
Authorization for Provider Enrollment and Change Self-Service
WF 16643 NOV 20
1
Section 1.
Section 3.
Provider Enrollment and Change Self-Service Basic Access: Allows users to maintain group demographics and composition only.
Provider Enrollment and Change Self-Service Full Access: Allows users to maintain group demographics and composition plus the ability to enroll and add new
practitioners to the group.
Each transaction creates an audit trail and provides user controlled demographic changes with the ability to check the status of your change requests online anytime
with a few mouse clicks.
Section 5.
Fax to 800-495-0812 or for questions call 877-258-3932
Section 2.
Select one role
Remove Provider Enrollment and Change Self-Service Access
Section 4.
John Doe
111-222-3333
F000000
John Doe
111-222-3333
F000000
Name
(Type
or Print Full Name of Each User)
Telephone Number
Provider Secured
Services
ID
Name
(Typ
e or Print Full Name of Each User)
Telephone Number
Provider Secured
Services
ID
Type 2 NPI(s) to remove
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