MEDICARE ADVANTAGE
STANDARDIZED PROVIDER INFORMATION CHANGE FORM
COMPLETE ALL APPLICABLE INFORMATION AND UTILIZE ‘SUBMIT’ BUTTON BELOW.
INCOMPLETE SUBMISSIONS MAY BE RETURNED UNPROCESSED.
NOT FOR NEW PROVIDERS, CONTRACTUAL MODIFICATIONS, OR CREDENTIALING CHANGES
( )
County:
3. ADDRESS INFORMATION
Product:
MA MMP PPO PSP
Group Name: Group NPI: Group TAX ID:
ENTER NEW OR ADDITIONAL ADDRESS BELOW ENTER OLD ADDRESSES TO BE TERMINATED BELOW
Address Type:
Primary Service Secondary Service
Correspondence
Address Type: Primary Service Secondary Service
Correspondence
Address Line 1: Address Line 1:
Address Line 2: Address Line 2:
City: City:
State: County: Zip: State: Zip:
Phone: Fax:Phone:
INFORMATION RELATED TO NEW OR ADDITIONAL SERVICE LOCATION
Hours Provider available
at this location
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open:
Close:
Patient Center Medical Home Yes No Location marked and visible from street Yes No
Location easily accessible via public transportation Yes No Accessible to members with disabilities Yes No
Designated parking for disabled Yes No Restrooms accessible for people with disabilities Yes No
Wheelchair ramps Yes No Auto-open external doors Yes No
Waiting room accommodate patients in wheelchairs/scooters Yes No Exam rooms with accessible equipment Yes No
If radiology offered, accessible to disabled patients Yes No ADA compliance on service animals Yes No
Materials available in braille and large print Yes No ASL interpretation available Yes No
Medicaid All Products
( ) ( ) Fax:( ) ( )
Secondary Specialty(ies):
Gender:
(Complete sections 2,4,5)
Effective Date:
1 of 2
*2. PROVIDER INFORMATION: *Section required
Last Name: First Name: Middle Initial:
Provider Former Name (if applicable):
Male Female
Primary Specialty:
IND NPI:
EPSDT (If applicable): Yes No
Accept Medicare & Medicaid: Yes No
Hospital Accreditation:
Hospital Affiliation 1: 2: 3:
Board Certification 1: 2: 3:
Language 1: 2: 3:
Provider Type:
PCP Ancillary Behavior Health Facility LTSS Specialist
Address Line 1:
Address Line 2:
City: State: County: Zip Code:
Provider Email Address:
* 1. INDICATE CHANGE(S) BEING SUBMITTED: Check all that apply
(*Sections 1,2 and 5 are required.)
Please include effective date for each item checked.
Provider Information
(Complete sections 2,3,5)
Effective Date:
Address Information
(Complete sections 2,3,5)
Effective Date: Group Name
(Complete sections 2,5)
Effective Date:
Indicate documents included: Provider Roster Other (List):
IF APPLICABLE, PLEASE ATTACH A SEPARATE LIST WITH THE NAMES AND NPI NUMBERS OF ALL OF THE PROVIDERS IN THIS GROUP FOR WHOM THE ADDRESS CHANGE IS APPLICABLE.
Panel Status
Phone:
933168 04/2020
Title/Degree:
