Fillable Participating provider Non-participating provider

Fill Online, Printable, Fillable, Blank Participating provider Non-participating provider Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Participating provider Non-participating provider

On average this form takes 17 minutes to complete

The Participating provider Non-participating provider form is 1 page long and contains:

  • 0 signatures
  • 17 check-boxes
  • 62 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
❑ Participating provider ❑ Non-participating provider
❑
❑ Change or add hospital affiliation: __________________________________
❑ Add specialty: ___________________________________________________
❑ Other: ___________________________________________________________
❑ Delete language:__________________________________________________
Old Service Information
(If more than one location, attach an additional form for each location)
Individual0name:_________________________________________
Group name: ___________________________________________
Address: ________________________________________________
City: ___________________________ State: ____ Zip: _________
Telephone: ________________________________________________
Fax: ( ______ ) __________________ Tax ID: __________________
Old Demographic Information
New Billing Information
(Form W-9 must be submitted with all tax ID updates)
Name: (As shown on your income tax return)
__________________________________________________________
Address: _________________________________________________
City: ____________________________ State: ____ Zip: __________
Telephone: _________________________________________________
Fax: _______________________________________________________
Tax ID: _______________ NPI: ______________________________
New Service Information
(If more than one location, attach an additional form for each location)
Primary service location? ❑ Yes ❑ No
Individual name: _________________________________________
Group name: ____________________________________________
Address: ________________________________________________
City: ____________________________ State: ____ Zip: _________
Telephone: _______________________________________________
Fax: ________________________ Tax ID: ____________________
New Demographic Information
❑ Par facility: ____________________________________________________
❑ Non-par facility: ________________________________________________
Effective date of new contract: ____________________________________
Requester initial: _________________________________________________
Internal use only
Contract Type
❑ Par professional: ______________________________________________
❑ Non-par professional: _________________________________________
❑ Special contract: ______________________________________________
❑ MCHCS: _____________________________________________________
PR02 • 6/16
Print name of authorized signature: ________________________________________ Title:__________________________________________________
Authorized signature: X ___________________________________________________________________________ Date: __________________
Email: _______________________________________ Telephone: ____________________________
Fax: ________________________________
Please fax or email completed form with additional documentation to:
Fax: (646) 473-7229 | Email: Providers@1199Funds.org
Please allow 45 days to process your request. Tax ID updates cannot be processed without a properly completed Form W-9.
Provider Demographic Information Change Request Form
Please type or print legibly to avoid processing delays.
❑ Group practice
❑ Add TIN
❑ Deactivate TIN
❑ Change TIN
❑ Add billing address
❑ Add language:________________________________
Old Billing Information
Name: (As shown on your income tax return)
_________________________________________________________
Address: _________________________________________________
City: ____________________________ State: ____ Zip: _________
Telephone:_________________________________________________
Fax:_______________________________________________________
Tax ID: ____________________ NPI: _________________________
❑ Individual provider
❑ Change billing address
❑ Add service address
❑ Delete service address
❑ Change service address
❑
Institution/Facility
Effective Date: __________________________
Change name (group or p
h
ysician): ________________________________
Current Provider Information
Provider: ______________________________________________ Email: _________________________________ Tax ID: ____________________
Specialty: ______________
___________________________ Area of interest:________________________________ NPI: ______________________
❑ No
Type of Change: (Check all that apply)
Board Certified:
❑ Yes
This Change Affects:
MONTH/DATE/YEAR
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Participating provider Non-participating provider

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document