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Care Provider Demographic Information Update

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Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 1
Care Provider Demographic Information Update
• The My Practice Profile tool on Link lets you view, update and attest to the care provider demographic
information UnitedHealthcare members see for your organization. Use the tool to make demographic
changes just one time, in one place — and get those updates into our systems more quickly. You can find
instruction about updating your information at UHCprovider.com/mypracticeprofile.
• If you can’t update demographic information online, use this form for a single care provider practitioner
update. For practices with two or more care provider practitioners, please use the Group/Organization
Demographic Information Update form at UHCprovider.com/mypracticeprofile.
• Incomplete forms will not be processed.
• UnitedHealthcare uses current data and the updates you provide to publish accurate care provider
directories. By submitting this form, you are confirming that these are the only changes needed at
this time.
• Fields with an asterisk (*) are required for practitioners providing care under all UnitedHealthcare plans.
• If additional space is required, please include a separate roster with this form.
• A W-9 form form is required when adding new tax ID numbers and making name changes.
• Index: Section I – Single Care Provider and Group/Organization Association Information
Section II – Adding or Updating a Single Care Provider
Section III – Maintaining Taxpayer ID Numbers, Addresses and Contact Information
Section IV – National Provider Identifier (NPI) Definitions and Requirements
Section V – Sign and Submit
Section I – Single Care Provider and Group/Organization Association Information
*Care provider name:
Last:
First: MI: Suffix:
 This is a name change. Attach a copy of the W-9 form for name changes.
Previous Care Provider Name:
Effective Change Date (MM/DD/YYYY):
*Tax ID Number (TIN):
Name of group or organization associated with this care provider/TIN:
Effective Change Date (MM/DD/YYYY):
Group/Organization National Provider Identifier (NPI) Number
Please refer to Section IV for details about NPI number requirements.
Is the group/organization an atypical provider?
Yes. NPI is not required.
No. *Complete the following NPI information:
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 2
NPI Number:
NPI Number Taxonomy Code:
NPI Number Issue Date (MM/DD/YYYY):
Basis for NPI Number:
NPI Number Level of Information:
Section II – Adding or Updating a Single Care Provider
Remove the following care provider (all questions are required)
Name:
NPI:
TIN: Effective Date (MM/DD/YYYY):
The care provider is leaving the group/contract TIN for the following reason:
Care Provider Retired Care Provider Deceased Care Provider Left Group
Care Provider Not Affiliated with TIN/Contract Provider Left Service Area Voluntary
Leave of Absence Incorrect Data Other (Personal, Sabbatical, etc.)
For PCPs no longer associated with a TIN, UnitedHealthcare will reassign members to the listed care
provider when available:
If we aren’t able to assign to your selected care provider, UnitedHealthcare will identify an acceptable
replacement.
Add the following care provider (all questions are required)
When adding a new care provider, answers to all questions are required. When updating a care provider’s
information, fill out only the updated information.
1. Date of birth (MM/DD/YYYY):
2. Gender: Male Female Unknown
3. Does the care provider have a Medicare identification number? Yes:
No
4. Does the care provider have a Medicaid identification number? Yes:
No
5. Is the care provider a primary care provider (PCP) or specialist? PCP Specialist
6. Is the care provider hospital-based operating solely in a hospital? Yes No
7. Is the care provider a hospitalist? Yes No
8. Does the care provider have hospital affiliations? Yes No
If Yes, list the hospital names next to the type of admitting privilege, which indicates the hospital affiliation type.
• Active (AC):
• Active Admitting (ACT):
• Active Non-Admitting (NAC):
• Adjunction Staff (ADJ):
• Admitting (ADM):
• Affiliate (AFF):
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 3
• Assistant Adjunction (ATA):
• Assistant Attending (ACA):
• Associate (ASC):
• Attending (ATT):
• Clinical Privileges (CLP):
• Consulting (CON):
• Consulting Admitting (CN):
• Consulting Non-Admitting (NCN):
• Courtesy (COU):
• Courtesy Admitting (CT):
• Courtesy Non-Admitting (NCT):
• Deferred (DAP):
• Honorary (HON):
• Non-Admitting (NAN):
• Provisional Non-Admitting (NPR):
• Unknown (UNK):
9. Remove the following hospital affiliations (hospital names):
10. Is the care provider accepting UnitedHealthcare members as new patients? Yes No
Care provider isn’t accepting UnitedHealthcare members as new or existing patients.
11. Does the care provider accept new Medicaid patients? Yes No
Care provider isn’t accepting new or existing Medicaid patients.
12. Does the care provider accept new Medicare patients? Yes No
Care provider isn’t accepting new or existing Medicare patients.
13. Care provider’s email address:
Not applicable
a. Is this email address for an individual care provider or the email address for an office location?
Care Provider Location
b. List this email address in the care provider directory? Yes No
14. Care provider’s website:
Not applicable
a. Is this an individual care provider’s website or the website for an office location?
Care Provider Location
b. List this website in the care provider directory? Yes No
15. Is the practitioner an Indian Health Service provider? Yes No
16. Does the care provider have telehealth service capability? Yes No
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 4
17. National Provider Identifier (NPI) Number
Please refer to Section IV for details about NPI number requirements
Is the care provider an atypical provider?
Yes. NPI is not required.
No. *Complete the following NPI Number information:
NPI Number:
NPI Number Taxonomy Code:
NPI Number Issue Date (MM/DD/YYYY):
Basis for NPI Number:
NPI Number Level of Information:
18. Care provider’s primary specialty:
a. Is the care provider board-certified for this specialty? Yes No
19. Care provider’s secondary/sub-specialty:
Not available
20. Care provider’s expertise (when applicable) with individuals:
With physical disabilities
With chronic illness
With HIV/AIDS
With serious mental illness
Who are homeless
Who are deaf or hard-of hearing
Who are blind or visually impaired
With co-occurring disorders
Who are transgender
Other specialties:
21. Care provider’s Primary degree: Secondary degree:
22. Care provider’s board certifications:
23. Care provider’s state licenses (please add dates as MM/DD/YYYY):
State: License: Effective Date: Expiration Date:
State:
License: Effective Date: Expiration Date:
24. For mid-level care providers, list the supervising physician’s information.
Name:
Specialty:
Mid-level care providers have a medical degree, but are not physicians. A mid-level provider can diagnose
and treat patients under the supervision of a licensed physician or independently as allowed by state law
and licensure.
25. Does the care provider have a Drug Enforcement Administration (DEA) registration number?
Yes:
Expiration Date (MM/DD/YYYY): No
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 5
26. Care provider cultural competency training dates (MM/DD/YYYY)
a. Communication Skills – Interpreter Services (CIS)
Effective Date:
Expiration Date:
b. Communication Skills – Language Availability (CLA)
Effective Date:
Expiration Date:
c. Communication Skills – Soft Skills (CSS)
Effective Date:
Expiration Date:
d. Financially Challenged Patients (FCP)
Effective Date:
Expiration Date:
e. Homeless (HL)
Effective Date:
Expiration Date:
f. LGBT Communities (LGB)
Effective Date:
Expiration Date:
g. People with Disabilities (PWD)
Effective Date:
Expiration Date:
h. Refugee or Immigrant Patients (RIP)
Effective Date:
Expiration Date:
i. Senior Care (SC)
Effective Date:
Expiration Date:
j. Unspecified (UNS)
Effective Date:
Expiration Date:
27. Is the care provider an Essential Community Provider (ECP)? An ECP serves mostly low-income,
medically underserved individuals. Yes No
Section III – Maintaining Taxpayer ID Numbers, Addresses and Contact Information
Updating the TIN may require also updating the corresponding address. Please make the address changes
on this form as needed and attach a copy of the W-9 for TIN additions, changes or updates to the TIN legal
owner.
*Tax ID Number (TIN) Change
Old TIN:
New TIN:
Legal Owner of New TIN:
Effective Date (MM/DD/YYYY):
Old TIN: If the care provider is a PCP, please provide the name of a care provider for member reassignment:
PCP Name:
UnitedHealthcare will reassign members to the listed care provider when available. If we are unable to
assign to your selected care provider, UnitedHealthcare will identify an acceptable replacement.
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 6
TIN Addition
TIN:
Legal Owner of TIN:
Effective Date (MM/DD/YYYY):
Group or organization associated with the additional TIN:
TIN Maintenance
TIN:
 Legal Owner Change (include copy of W-9)
Old Legal Owner:
New Legal Owner:
Effective Date (MM/DD/YYYY):
Telephone or Fax Number Update
TIN:
Provide any additional telephone or fax updates on a separate roster and include the following information.
Address associated with this update: Billing Practice Location Mailing Credentialing
Street:
Suite/Other:
City: State: County: ZIP+4:
 Phone Number Update Change Add only Delete only
TIN:
Add phone: Extension:
Delete phone:
Extension:
Publish this practice location phone number change or add in the UnitedHealthcare care provider
directory as:
a. A UnitedHealthcare Community Plan participating care provider Yes No N/A
b. A UnitedHealthcare Medicare Advantage contracted care provider Yes No N/A
c. A UnitedHealthcare commercial participating care provider Yes No N/A
If you choose not to display the phone number in our directory, one of the following reasons must apply:
Care provider is not active due to taking an extended leave of absence.
Care provider is in the process of being removed from the UnitedHealthcare network.
Care provider is under investigation for fraud, licensure or quality issues.
Decline to publish care provider information because of one or more California-specific exemptions.
Please attach a signed statement.
The care provider is currently enrolled in the state’s Safe at Home program.
The care provider fears for their safety or their family’s safety because of their affiliation with a health
care service facility or because they provide health care services.
This location, facility or any of its care providers, employees, volunteers or patients is or was the
target of threats or acts of violence within the past year.
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 7
Fax Update Change Add only Delete only
Add fax:
Delete fax:
Address Updates
Delete Address
TIN:
Provide any additional addresses on a separate roster and include the following required information.
Address type: Billing Practice Location Mailing Credentialing
Street:
Suite/Other:
City: State: County: ZIP+4:
Effective Date (MM/DD/YYYY):
Add Billing, Mailing or Credentialing Address
TIN:
Provide any additional addresses on a separate roster and include the following required information.
Address type: Billing Mailing Credentialing
Street:
Suite/Other:
City: State: County: ZIP+4:
Phone:
Extension: Fax:
Effective Date (MM/DD/YYYY):
Billing address correspondence: Primary Secondary None
Practice Location Address:
TIN:
Add New Address Update Current Address
Additional practice location addresses to be added for the group/organization must be listed on a
separate roster with all following required/applicable information.
Street:
Suite/Other:
City: State: County: ZIP+4:
Phone: Extension: Fax:
Effective Date (MM/DD/YYYY):
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 8
For this practice location address, all of the following information is required:
1. This is the primary practice location address. Yes No
2. The practice location address, for correspondence purposes, is: Primary Secondary None
3. For this practice location address, publish in the UnitedHealthcare care provider directory as:
a. A UnitedHealthcare Community Plan participating care provider Yes No N/A
b. A UnitedHealthcare Medicare Advantage contracted care provider Yes No N/A
c. A UnitedHealthcare commercial participating care provider Yes No N/A
Only care providers who regularly practice at the specified location may be listed in the directory.
If you choose not to display the address in our directory, one of the following reasons must apply:
 Care provider is not active due to taking an extended leave of absence.
 Care provider is in the process of being removed from the UnitedHealthcare network.
 Care provider is under investigation for fraud, licensure or quality issues.
 Decline to publish care provider information because of one or more California-specific
exemptions. Please attach a signed statement.
 The care provider is currently enrolled in the state’s Safe at Home program.
 The care provider fears for their safety or their family’s safety because of their affiliation with
a health care service facility or because they provide health care services.
 This location, facility or any of its care providers, employees, volunteers or patients is or was
the target of threats or acts of violence within the past year.
4. National Provider Identifier (NPI) Number
Please refer to Section IV for details about NPI number requirements.
*NPI number associated with the practice location address (not required for atypical providers):
Not applicable
NPI number issue date (MM/DD/YYYY) associated with the practice location address:
NPI number taxonomy code associated with the practice location address:
5. *Primary specialty associated with this practice location address:
6. Additional specialty associated with this practice location address:
a. Additional specialty effective date (MM/DD/YYYY):
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 9
7. This location’s expertise (if applicable) with individuals:
With physical disabilities
With chronic illness
With HIV/AIDS
With serious mental illness
Who are homeless
Who are deaf or hard-of hearing
Who are blind or visually impaired
With co-occurring disorders
Who are transgender
Other specialties:
8. Practice location address office hours:
Monday:
a.m. to p.m. Closed Open 24 hours
Tuesday:
a.m. to p.m. Closed Open 24 hours
Wednesday:
a.m. to p.m. Closed Open 24 hours
Thursday:
a.m. to p.m. Closed Open 24 hours
Friday:
a.m. to p.m. Closed Open 24 hours
Saturday:
a.m. to p.m. Closed Open 24 hours
Sunday:
a.m. to p.m. Closed Open 24 hours
9. Is this location a Federally Qualified Health Center? Yes No
10. Is this location handicap accessible? Yes No
If Yes, select the types of accessibility:
Exam Room (E)
Exam Table/Scale/Chair (T)
Exterior Building (EB)
Gurneys & Stretchers (G)
Interior Building (IB)
Parking (P)
Portable Lifts (PL)
Restroom (R)
Radiologic Equipment (RE)
Signage & Documents (S)
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740 10
11. List the languages associated with this practice location address, including American Sign
Language, if applicable.
Spoken by:
Care Provider:
Staff:
Interpreter (ITP):
Interpreter and Care Provider (ITP PHYS):
Interpreter and Staff (ITP STAFF):
All:
Written by:
Care Provider:
Staff:
Interpreter (ITP):
Interpreter and Care Provider (ITP PHYS):
Interpreter and Staff (ITP STAFF):
All:
Is a skilled medical interpreter line available if this practice location doesn’t have a skilled medical
interpreter? Yes: (
) No
12. Patient age restrictions associated with this practice location (ages in numerals; 0-999):
13. Patient gender restrictions associated with this practice location:
Male Only Female Only No Restrictions Restrictions are Unknown
14. If the care provider is participating in a UnitedHealthcare Community Plan network at this location:
State:
Medicaid ID:
15. If the care provider is participating in a UnitedHealthcare Medicare or Medicare Advantage network
at this location:
Medicare ID:
11
© 2018 United HealthCare Services, Inc.
Doc#: PCA-1-010588-04302008_08212018
DRG#: 0007740
Section IV - National Provider Identifier (NPI) Number Definitions and Requirements
The National Provider Identifier (NPI) is a federal requirement; however, atypical providers are not
required to have an NPI number. Atypical providers are individuals and organizations that furnish ‘atypical’
or non-traditional services that are indirectly health care related, such as taxi service, home and vehicle
modifications, habilitation and respite services.
Basis for NPI Number NPI Number Level of Information
C – Entity whose name is
on the W-9
Tax ID number and name filed on the W-9: Legal owner of TIN - does not bill for medical services.
Indicate if it’s a Social Security number (SSN) or TIN.
D – Department
Department name: If the organization or sub-part was enumerated on the basis of a particular de-
partment, provide the Department Name that the NPI was based on, and designate this with a “D”
in the “Basis for NPI” field. Insert the Department Name in the “Level Information” field.
L – License
License number and state or state code: If the organization or sub-part was enumerated by
License, provide the state or state code and License Number that the NPI was based on, and des-
ignate this with an “L” in the “Basis for NPI” field. Insert the License Number and state or state code
in the “Level Information” field.
P – Place of service
address
Place of service address (street, city, state, ZIP+4) If the organization was enumerated by place of
service address, provide the street address that the NPI was based on and designate this with a
“P” in the “Basis for NPI” field. Insert the Place of Service address in the “Level Information” field.
List NPI number for each Group/Organization Place of Service
T – Tax ID number and
provider name
Tax ID number and Provider Name where care provider is not the same on the W-9, but bills with
this TIN. Indicate whether the Tax ID number is a SSN or TIN.
X – Taxonomy
NUCC Taxonomy Code: If the organization or sub-part was enumerated by a NUCC Taxonomy
code, provide the Taxonomy Code that the NPI was based on and designate this with an “X”
in the “Basis for NPI” field. Place the NUCC Taxonomy Code in the “Level Information” field.
O – Other
Any other basis for the NPI number: Provide any other basis for NPI number in the “Basis for
NPI Number” field and designate as “O”, with a description of the basis for that NPI in the “Level
Information” field.
M – Name
Insert the name of the care provider (physician or allied health professional) in the “Level
Information” field.
Section V – Sign and Submit
Submit completed forms, required information and any additional rosters to hpdemo@uhc.com.
*Person completing this form:
*Date:
Title:
*Telephone: ( ) *Office Contact:
Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health
Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA
UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare
of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc.,
UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans
(CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care
Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan,
California (USBHPC), United Behavioral Health (UBH) or its affiliates.
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Care Provider Demographic Information Update

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Completed 20 November 2020

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