Fillable Provider Update Form Please note: This form is

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Provider Update Form
Please note: This form is intended for providers who are already credentialed with FCH. If you would like to become
credentialed with FCH, please visit www.fchn.com/Providers and click on the Network Participation link.
Contact Name (First Name): Contact Phone: Contact E-mail Address: Effective Date of Change:
Provider Name: Provider NPI: Taxonomy:
TYPE OF PROVIDER CHANGE: ADD REMOVE
Tax ID Number:
Street Address: City: State: Zip Code + Four:
Check Appropriate Type of Address:
Physical Practice Address (not PO Box) Billing Mailing Credentialing
Phone Number:
Hospital Affiliation: Languages Spoken (other than
English):
Address ADA Accessible:
Yes No
Women’s Health OB Deliveries Telemedicine Capacity (maximum number of patients that practitioner manages):
TYPE OF ADDRESS CHANGE: ADD REMOVE
Tax ID Number:
Street Address: City: State: Zip Code + Four:
Check Appropriate Type of Address:
Physical Practice Address (not PO Box) Billing Mailing Credentialing
Phone Number:
Hospital Affiliation: Languages Spoken (other than
English):
Address ADA Accessible:
Yes No
Gender Limitations: Minimum Age: Maximum Age:
Male Female None
Women’s Health OB Deliveries Telemedicine Capacity (maximum number of patients that practitioner manages):
TYPE OF ADDRESS CHANGE: ADD REMOVE
Tax ID Number:
Street Address: City: State: Zip Code + Four:
Check Appropriate Type of Address:
Physical Practice Address (not PO Box) Billing Mailing Credentialing
Phone Number:
Hospital Affiliation: Languages Spoken (other than
English):
Address ADA Accessible:
Yes No
Gender Limitations: Minimum Age: Maximum Age:
Male Female None
Women’s Health OB Deliveries Telemedicine Capacity (maximum number of patients that practitioner manages):
Pay-To Address: As a Preferred Provider Organization (PPO), we do not store your pay-to address (where you want your checks to be sent) in our
system. This address should be relayed on your claims. For electronic (EDI) claims, submit this address in loop 2010 AB, and on a paper claim (CMS
1500 or HCFA), this address should be in box 33.
OTHER CHANGES: CORPORATE PERSONAL
Changes in this section assume that no other changes are needed. For example, if the information provided below is the Old and New Tax ID
Number, we will update only the Tax ID Number and no other changes to existing information will be made.
OLD NEW
Corporate Name
(W-9 form required)
Tax ID Number
(W-9 form required)
Personal Name
Individual NPI Number
Phone
(Practice location)
Fax
(Practice location)
2 of 2
First Choice Health
|
One Union Square
|
600 University Street, Suite 1400
|
Seattle, WA 98101
SUBMISSION INSTRUCTIONS:
Complete the form, download or save a copy, and send it (including W-9 and other pertinent documentation as
needed) as an email attachment to ppolemaintenance@fchn.com, indicating ‘Provider Update’ in the subject line.
(NOTE: If your internet browser does not allow typing in the llable form, you must download the form and use
free Adobe Acrobat Reader software to complete it.)
If you are unable to email the form, send it via fax to (206) 268-2940, ATTN: Provider Information Department.
Any changes sent to our Provider Information team will take approximately 30 business days to implement.
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Completed 2 October 2020

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