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Demographic Update Web Form Quick Reference Guide (QRG)

Tips for filling out the Provider Demographic Updates form:

Supporting Documentation Required

Please ensure that a supporting document is attached
for the following types of updates:

  • Medical/DEA License Updates    
  • Name Change·        
  • Service Location·        
  • Practitioner Termination·        
  • W-9 Submission

The supporting documentation should be written on your company letterhead.

Accepting Patients Status

Accepting New Patients: To open panels to allow new patients to be assigned to a practitioner or to display as accepting new patients on Find-A-Provider.

Existing Patients Only: To prevent new patients from being assigned and maintain existing patients only.

Referral Only: To only accept new patients by referral from a primary care provider.

Not Accepting New Patients: Closes panels to prevent member assignment and to display as not accepting new patients on Find-A-Provider.

Email Address

Type of Update: Indicate whether the update is to add, remove, or change an e-mail address.

Type of Email Address: Indicate whether the e-mail address is public-facing, which will display in our provider directories or a credentialing-only e-mail, which is internal only.

Medical/DEA License Update

Attachment: Please provide an unexpired copy of the medical license. Once the license is validated, any applicable payment restrictions will be removed from the provider profile.

Service Location

Address: Please enter the complete address of the impacted locations.

Attachment: Please include a formal request to make changes (add/terminate/suppress) the location on company letterhead that includes:

  • Complete address, including applicable suite number(s), city, state, and zip code.
  • Contact information (phone/fax/website)
  • Effective date

We are only able to display a maximum of five locations, per practitioner, per provider group.

Practitioner Termination

Line of Business: Select all applicable line(s) of business that the practitioner termination applies to.

Termination Date: List the effective date of the termination

Reason for Termination: Select the most applicable option from the drop-down menu.

Type of Termination: Select to whom the termination request applies.

W-9

Attachment: Please include a W-9 signed within 12 months of the submission date. The address listed on the W-9 will be loaded as the billing address.

Website

Website Address/URL: This website will be loaded to the applicable practitioner and/or provider record and displayed on Find-A-Provider, if eligible.