Change/Update Provider InformationAll fields with an asterisk (*) MUST be completed FacebookThis field is for validation purposes and should be left unchanged.Contact InformationPlease list your contact information below. By default all correspondence will be conducted through the contact person identified in this section.Contact Information*First NameLast NamePhoneEmail* General Information**If making a change for multiple providers, please submit a roster below. Ex. adding a location for multiple providersTax ID*Individual NPIProvider Name & Degree First Last Degree RequestReason for Submission (select all that apply) Add Location Add Location (multiple) Add Phone/Fax # Add Group NPI Add Medicaid # Add Medicare # Add Provider Specialty Change Location Change Group Name Change Office Hours Change Provider Acceptance of New Patients Change Provider Panel Designation Change in Directory Designation Change Phone/Fax # Change Provider Specialty Change Tax ID Change Effective Date Provider Name Change Terminate Location Terminate Provider from Group/Practice CommentsPlease provide any information that might assist us in processing your request.Old AddressList provider's old location. Street Address Address Line 2 City State ZIP / Postal Code New Location TypePrimaryAlternateBillingCorrespondenceGroup NameGroup NameGroup NameGroup NameBilling/Pay-to NameBilling/Pay-to NameCorrespondence NameCorrespondence NameGroup NPINew AddressList provider's new location. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Does provider provide EPSDT services at this site?* Yes No Does practice provide American Sign Language services at this time?* Yes No Does provider provide Telemedicine services at this site?* Yes No Does this site participate in KHIE?* Yes No To which location does this update apply?Phone/FaxList new phone/fax.PhoneFax Location AccessibilitiesIndicate Yes (Y) or No (N).Handicap AccessibilityTDD HearingBus Route Directory DesignationDo you wish to list this location in the provider directory? Indicate Yes or No. Yes No Office HoursMon.Tues.Wed.Thurs.Fri.Sat.Sun. Panel/Acceptance of New Patient DesignationIf Provider participates with Medicaid and/or Medicare Advantage via Center Care, please indicate panel/acceptance of new patient designation for this particular location. PCP - Open Panel PCP - Closed Panel Specialist - Accepting New Patients Specialist - Not Accepting New Patients N/A Supervising Physician Name*If provider is a Nurse Practitioner or Physician Assistant, please list the name of provider's Supervising Physician. If provider is neither, please type N/A.Change in Tax ID InformationOld TINNew TIN Change in Group NameOld Group NameNew Group Name Provider Name Change*Previous Provider NameNew Provider Name Change in SpecialtyList Provider's New SpecialtyAddition of SpecialtyList Provider's New SpecialtySpecialty TypeIs the new specialty the provider's Primary or Secondary specialty? Primary Secondary Upload for multiple locationsYou have chosen to add multiple locations for this provider. Please upload a roster of locations to which this update applies. Drop files here or Select files Max. file size: 50 MB. Roster Upload (if making a single change for multiple providers) Drop files here or Select files Max. file size: 50 MB. Reason for TerminationPlease list the reason for the provider's termination.AddressList location to terminate. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Medicaid #If PCP, what is the Maximum Panel Capacity for Medicaid?Medicare #If PCP, what is the Maximum Panel Capacity for Medicare?Effective Date* MM slash DD slash YYYY Please explain the reason for the change in effective date in the comments section below.CommentsList any comments that might assist us in processing your request.Upload FilesPlease upload supporting documentation here. Drop files here or Select files Max. file size: 50 MB. Upload Supporting Documentation*Please upload supporting documentation as proof of name change (ex. Medical License) Drop files here or Select files Max. file size: 50 MB.
