Demographics Changes 

DEMOGRAPHIC CHANGES **ALL FIELDS MUST BE COMPLETE FOR ANY CHANGES TO BE REPORTED TO HEALTH PLANS
Some Health Plans do not allow retroactive effective dates - Report ALL demographic changes at least 30 days in advance.
CURRENT CLINICAL
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI


Primary Clinical Location

Retain this address and ADD new (section below)

Secondary Clinical Location

Remove This address effective
NEW INFORMATION CLINICAL
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI


Primary Clinical Location
Effective Date

Secondary Clinical Location
Effective Date
CURRENT REMITTANCE (BILLING)
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI


Retain this address

Remove This address effective
NEW INFORMATION REMITTANCE (BILLING)
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI

  Effective Date
CURRENT CORRESPONDENCE (MAILING)
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI


Retain this Address

Remove This address effective
NEW CORRESPONDENCE (MAILING)
Name

NPI

Current Address

Suite

City

State

Zip Code (9 digit)

Phone

Fax

Tax ID# (W-9 Required)

Group Name

Type II NPI

  Effective Date
CONTACT INFORMATION
Office Manager Name

Phone

Fax

Email
Remittance Contact Name

Phone

Fax

Email
Credentialing Contact Name

Phone

Fax

Email
NOTE: A telephone AND fax number is required for ALL locations. If a phone/fax is not listed it will default to the primary address phone/fax numbers.