Fillable Provider Information Update/Change Fill out the Provider section (Sanford Health Plan)

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Provider Information Update/Change Fill out the Provider section (Sanford Health Plan)

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File type: PDF

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HP-0678 03-2021
Provider Information
Update/Change
Fill out the Provider section of this form if you have a practitioner update. Fill out the facility section if you have a facility
update. We request a 60-day notice to be able to communicate these changes to our members. If more room is
needed, please attach an additional sheet listing your changes.
Clinic/Facility name:
Tax ID number:
Date:
Name
Title
Phone (person filling out this form)
Signature
Email
Add/Remove Provider
If additional room is needed for provider changes, please list them on a separate sheet and include it with this completed form.
Provider name:
Title:
NPI:
SSN:
Provider Email:
License number:
State:
Exp. Date:
Practicing specialty:
Languages:
Clinic/Hospital Name:
Phone:
Address:
City/State:
Zip:
Tax ID:
Group NPI:
Primary site? Yes No
Accepting new patients? Yes No
Directory suppress? Yes No
Practicing As: Hospital Based Only
Hospitalist
Locum Tenens
Urgent Care
Resident
ADD REMOVE
Reason employment ended:
Effective date:
Provider Demographic Change: provide legal document
Provider NPI:
Provider’s previous name:
Provider’s new name:
Old license number:
State:
New license number:
State:
Clinic/Facility Name Change
Previous Clinic Name:
New Clinic Name:
Effective Date:
Facility NPI number:
Billing NPI number:
Clinic/Facility is ADA Compliant
Tax Identification Number Change: submit a completed W-9 form
Previous Tax ID number:
New Tax ID number:
Profit Non-profit
Effective Date:
List entities included:
Telephone number change
Previous phone number:
New phone number:
Effective date:
Clinic phone Billing office Central business office Other
Physical/Mailing/Billing address change
Office/Facility address (physical location) Mailing location Billing address
Effective date:
Previous physical:
New physical:
Previous mailing:
New mailing:
Previous billing:
New billing:
*Please fax completed form to Provider Relations at (605) 328-7224
Provider
Facility
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Provider Information UpdateChange Fill out the Provider section (Sanford Health Plan)

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Completed 20 May 2021

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