Provider Informaon Change Form
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Parcipang provider Non-parcipang provider
Current Provider Informaon
Provider name: __________________________________________ Email: ______________________________________________
Specialty: _____________________________ NPI: ____________________________ Tax ID: _____________________________
Provider Change Informaon
This change aects:
Group pracce Individual provider Instuon/Facility Date change will take eect: _______ / _______ / _______
Month Date Year
Type of Change (Please check all that apply)
Add TIN Add service address Change name (group or physician): _____________________
Deacvate TIN Change service address Change or add hospital aliaon: ______________________
Change TIN Change billing address Add specialty: ______________________________________
Add billing address Delete service address Add praccing services: ______________________________
New Demographic Informaon
Old Demographic Informaon
New Service Informaon:
(If more than one locaon, aach an addional form for each locaon)
Primary service locaon? Yes No
Individual name: ______________________________________
Group name: _________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ___________________________ Tax ID: _______________
Old Service Informaon:
(If more than one locaon, aach an addional form for each locaon)
Individual name: ______________________________________
Group name: _________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ___________________________Tax ID: _______________
New Billing Informaon:
(W-9 form must be submied with all Tax ID updates)
Name: (As shown on your income tax return)
____________________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ________________________________________________
Tax ID: ________________ NPI: _________________________
Old Billing Informaon:
Name: (As shown on your income tax return)
____________________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ________________________________________________
Tax ID: ________________ NPI: _________________________
Print name and tle of authorized signature: _____________________________________________________________
Authorized signature: X __________________________________________________ Date: _____________________
Title: ____________________________________________ Email: ___________________________________________
Telephone: ____________________________________________ Fax: _______________________________________
Please fax or email completed form with addional documentaon to:
Fax: (682) 885-8403 | Email: CCHPNetworkDevelopment@cookchildrens.org
Please allow 10 business days to process your request. Tax ID updates cannot be processed without a properly completed W-9 form.
ND-PD01 RevNov20
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