Fillable Provider Change of Information Form

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Provider Change of Information Form

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The Provider Change of Information Form form is 2 pages long and contains:

  • 0 signatures
  • 14 check-boxes
  • 65 other fields

Country of origin: OTHERS
File type: PDF

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Provider Name Specialty
Individual NPI Today’s Date
Desired Eective Date
___________________________________________
Type of Request (Check all that apply)
Change of practice locations
Change to billing/remit, phone, email, suite, clinic name
Additional practice location
Change of Tax ID number
Please provide any additional details about the reason for your request.
What is the scope of your practice?
Do you schedule and manage patients independent of a supervising physician?
Yes No
Physical address
City State Zip
Phone #
( )
Fax #
( )
Billing address
City State Zip
Billing phone #
( )
Billing fax #
( )
Tax I.D.
Clinic Name
Clinic manager name Email
Additional offices/locations where you practice today (please list below)
Medical Behavioral Health Dental APP Other (describe) _________________________
Previous office information (what Selecthealth has on file)
Addition of Tax ID number
Request for additional networks
Other (please explain)
Continued on page 2...
NOTE: For requests requiring new contracts, effective dates will
be contingent on the date when the new contract is executed.
Provider Change of Information Form
© 2019 SelectHealth. All rights reserved. 4879 Revised 10/20
New office information or request information (complete as applicable to change request)
Return completed form, W-9, and verification of malpractice information (COI) to:
Physical Address
City State Zip
Phone #
( )
Fax #
( )
Billing Address
City State Zip
Billing Phone #
( )
Billing Fax #
( )
Tax I.D. W-9 Attached: Yes
No
Claims should pay to (select ONE) Self Group
Office Manager Name Effective Date of Change
/ /
Office Manager Email Address
Covering/collaborating provider
# days/week you will practice at this or other locations
Accepting new patients at this location?
Commercial Yes No
SelectHealth Advantage
®
Yes No
SelectHealth Community Care
®
(medical only) Yes No
If adding a location, which location will be primary?
Will the change require a new or revised directory listing? Yes No
Mail: Fax:
Attn: Provider Development 801-442-0776
SelectHealth
5381 Green St.
Murray, UT 84123
Questions? Contact Provider Development at 800-538-5054.
...Continued from page 1
Email:
provider.development@selecthealth.org
NOTE: This response is required; must be a participating provider from a similar specialty.
NOTE: W-9 must be submitted if changing Tax I.D. or billing information.
DISCLAIMER: Decisions on requests are based on SelectHealth membership access and business needs.
All requests are subject to approval by the SelectHealth Panel Committee.
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Provider Change of Information Form

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Completed 13 January 2022

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