Fillable Provider Informaon Change Form Parcipang provider Non-parcipang provider (Cook Children's Health Plan)

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Provider Informaon Change Form Parcipang provider Non-parcipang provider (Cook Children's Health Plan)

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The Provider Informaon Change Form Parcipang provider Non-parcipang provider (Cook Children's Health Plan) form is 1 page long and contains:

  • 2 signatures
  • 19 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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Provider Informaon Change Form
Please type or print legibly to avoid processing delays.
❏ 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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Provider Informaon Change Form Parcipang provider Non-parcipang provider (Cook Children's Health Plan)

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Completed 7 May 2021

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