Fillable Hcp Change Form Tn (Cigna Medicare Providers)

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Hcp Change Form Tn (Cigna Medicare Providers)

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The Hcp Change Form Tn (Cigna Medicare Providers) form is 2 pages long and contains:

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  • 26 check-boxes
  • 144 other fields

Country of origin: US
File type: PDF

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STANDARDIZEDPROVIDERINFORMATIONCHANGE FORM
COMPLETE ALL APPLICABLE INFORMATION AND UTILIZE ‘SUBMIT’ BUTTON BELOW.
INCOMPLETE SUBMISSIONS MAY BE RETURNED UNPROCESSED.
NOT FOR NEW PROVIDERS, CONTRACTUALMODIFICATIONS,OR CREDENTIALING CHANGES
1 of 2
*2. PROVIDER INFORMATION: *Section required
Last Name:
First Name:
Middle Initial:
Provider Former Name (if applicable):
Gender:
☐
Male
☐
Female
Primary Specialty:
IND NPI:
IND TAX ID:
EPSDT (If applicable) :
☐
Yes
☐
No
Accept Medicare & Medicaid:
☐
Yes
☐
No
Hospital Accreditation:
Hospital Affiliation 1:
2:
3:
Board Certification 1:
2:
3:
Language 1:
2:
3:
Provider Type:
☐
PCP
☐
Behavior Health
☐
Facility
☐
LTSS
☐
Specialist
Address Line 1:
Address Line 2:
City:
State:
County:
Zip Code:
Provider Email Address:
3. ADDRESS INFORMATION (If adding or changing TIN or Group NPI, please include a copy of the W9.)
Product:
☐
MA ☐ MMP ☐ Medicaid ☐ All Products
Group Name:
Group NPI:
Group TAX ID:
ENTER NEW OR ADDITIONAL ADDRESS BELOW
ENTER OLD ADDRESSES TO BE TERMINATED BELOW
Address Type:
☐
PrimaryService
☐
SecondaryService
☐
Correspondence
Address Type:
☐
PrimaryService
☐
SecondaryService
☐
Correspondence
Address Line 1:
Address Line 1:
Address Line 2:
Address Line 2:
City:
City:
State: County: Zip:
State: County: Zip:
Phone: Fax:
Phone: Fax:
INFORMATION RELATED TO NEW OR ADDITIONAL SERVICE LOCATION
Hours of Operation:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Open:
Close:
Patient Center Medical Home
☐Yes
☐No
Location marked and visible from street
☐Yes
☐No
Location easily accessible via public transportation
☐Yes
☐No
Accessible to members with disabilities
☐Yes
☐No
Designated parking for disabled
☐Yes
☐No
Restrooms accessible for people with disabilities
☐Yes
☐No
Wheelchair ramps
☐Yes
☐No
Auto-open external doors
☐Yes
☐No
Waiting room accommodate patients in wheelchairs/scooters
☐Yes
☐No
Exam rooms with accessible equipment
☐Yes
☐No
If radiology offered, accessible to disabled patients
☐Yes
☐No
ADA compliance on service animals
☐Yes
☐No
Materials available in braille and large print
☐Yes
☐No
ASL interpretation available
☐Yes
☐No
*1. INDICATE CHANGE(S) BEING SUBMITTED: Check all that apply (*Sections 1,2 and 5 are required.)
Please include effective date for each item checked.
☐
Provider Information (Complete sections 2,3,5)
Effective Date: __________
☐
Panel Status (Complete sections 2,4,5)
Effective Date: __________
☐
Address Information (Complete sections 2,3,5)
Effective Date: __________
☐
Group Name (Complete sections 2,5)
Effective Date: __________
Indicate documents included:
☐
Provider Roster
☐
Other (List):
IF APPLICABLE, PLEASE ATTACH A SEPARATE LIST WITH THE NAMES AND NPI NUMBERS OF ALL OF THE PROVIDERS IN THIS GROUP FOR WHOM THE ADDRESS CHANGE IS APPLICABLE .
STANDARDIZEDPROVIDERINFORMATIONCHANGE FORM
COMPLETE ALL APPLICABLE INFORMATION AND UTILIZE ‘SUBMIT’ BUTTON BELOW.
INCOMPLETE SUBMISSIONS MAY BE RETURNED UNPROCESSED.
NOT FOR NEW PROVIDERS, CONTRACTUALMODIFICATIONS,OR CREDENTIALING CHANGES
2 of 2
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation.
The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2016 INT_16_41716 03242016
3. ADDRESS INFORMATION (If adding or changing TIN or Group NPI, please include a copy of the W9.)
Product:
☐
MA ☐ MMP ☐ Medicaid ☐ All Products
Group Name:
Group NPI:
Group TAX ID:
ENTER NEW OR ADDITIONAL ADDRESS BELOW
ENTER OLD ADDRESSES TO BE TERMINATED BELOW
Address Type:
☐
PrimaryService
☐
SecondaryService
☐
Correspondence
Address Type:
☐
PrimaryService
☐
SecondaryService
☐
Correspondence
Address Line 1:
Address Line 1:
Address Line 2:
Address Line 2:
City:
City:
State: County: Zip:
State: County: Zip:
Phone: Fax:
Phone: Fax:
INFORMATION RELATED TO NEW OR ADDITIONAL SERVICE LOCATION
Hours of Operation:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Open:
Close:
Patient Center Medical Home
☐Yes
☐No
Location marked and visible from street
☐Yes
☐No
Location easily accessible via public transportation
☐Yes
☐No
Accessible to members with disabilities
☐Yes
☐No
Designated parking for disabled
☐Yes
☐No
Restrooms accessible for people with disabilities
☐Yes
☐No
Wheelchair ramps
☐Yes
☐No
Auto-open external doors
☐Yes
☐No
Waiting room accommodate patients in wheelchairs/scooters
☐Yes
☐No
Exam rooms with accessible equipment
☐Yes
☐No
If radiology offered, accessible to disabled patients
☐Yes
☐No
ADA compliance on service animals
☐Yes
☐No
Materials available in braille and large print
☐Yes
☐No
ASL interpretation available
☐Yes
☐No
4. PRIMARY CARE PANEL STATUS: May be impacted by contract terms and follow-up may be required.
☐
Openpanel
☐
Closepanel
☐
Nursing homeonly
☐
Accepting existing patientsonly
Other(pleasespecify):_________________
*5. CONTACT PERSON SUBMITTING INFORMATION: *Section required.
Name:
Title:
Phone:
Fax:
Email:
Date of Submission:
SUBMIT FORM
RESET FORM
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Hcp Change Form Tn (Cigna Medicare Providers)

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Completed 16 July 2020

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