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Provider Demographic Updates

Providers are strongly encouraged to utilize this form to submit demographic updates. Please fill out the form below with all necessary details, including all required documentation. When selecting the type of update, please review the critical requirements in bold to ensure accuracy in processing your request. Please also be aware that omitting necessary documentation may result in a delay in processing your request. Prior to completing the form, please review the following information:

  • Requests to join our network are not processed using this form. To request to join our network or add a product to your existing agreement, please use our Network Participation Request Form. Once you have completed this form, please allow up to fourteen (14) days for our Contracting team to review your request.  
  • This form does not facilitate requests for ownership changes. To process a change of ownership of your entity, please visit our Change of Ownership Request Form.
  • Please submit all claims and non-demographic update inquiries through our Secure Web Portal. 
  • This form does not process any changes to member data. For member-related inquires, please login to the Member Portal.
  • This form is not intended to add a new practitioner to an existing group. To add a new practitioner to an existing, participating group, please download our LOAP/Practitioner Roster Form (XLSM) and submit a Provider Enrollment Request.

 

IMPORTANT NOTICE: Please consolidate all practitioner updates from your practice into a single submission. Multiple individual requests for the same update will not be processed.

For updates applicable to your entire group:

  • Submit one ticket only
  • Attach instructions on your company letterhead
  • Clearly indicate how the update applies to all relevant practitioners

This form is exclusively for demographic updates. Claims, contracting and practitioner enrollment-related inquiries must be submitted through their designated channels.

Thank you for your cooperation.

Need help?

Follow these tips for completing the Provider Demographic Updates form.

Quick Reference Guide
Are you a:
Please no dashes "-"
Is this update for only one practitioner in your Group, or does it affect the entire Group Itself? required *
Line(s) of Business Impacted required *
Type of Update required *

*For these updates with the asterisk listed above, documentation will be needed to process this type of update.

Before we can process specialty changes for Medicaid products, please ensure all changes are first recorded on the Provider Master List (PML). We can only update specialties that appear on the PML.

Does your practice provide ABA services? required *
Please indicate your patient panel status: required *
If Updating Email Address do you want to add, remove, or change current email address? required *
If adding an email address please select what type of email address is being added: required *

Please upload a copy of the unexpired license using the Supporting Document upload button.

Please upload a copy of supporting, legal documentation of for the practitioner name change AND an updated medical license using Supporting Document upload button.

Please enter the service location address that the change in office hours applies to:

Please enter the office hours for each day of the week:

Please enter the service location that the change in phone/fax numbers apply to:

Before submitting a request to add a new service location, please make note of the following:

  • Please ensure that the location is not already listed in our Medicaid, Ambetter or WellCare Find-a-Provider directories.
  • A maximum of five (5) service locations will be displayed per practitioner, per provider group.
  • Please only submit updates for service locations where the practitioner is actively providing services to members.
  •  If our data validation vendor determines that a member cannot schedule an appointment using the provided phone number and service location, the record will be removed from the directory.
  • If you need to make multiple updates, like adding an address or terminating one, please combine all changes into a single request written on your company letterhead. We will process your attached request as indicated, which will supersede your form selections.

Medicaid | Ambetter | Wellcare

Please enter the service location address:

Please select which option is needed for this update: required *
Display Location in Directory: required *
Location Change Applies to: required *

To streamline group changes, please submit a single request for the
entire group. We will apply the requested changes to all participating
practitioners within the group. Individual submissions by practitioners are not
required.

Ages of Patients Seen:

Select all lines of business the specialty/taxonomy update applies to: required *

Please upload a copy of training and education using Supporting Document
upload button. Please note that for Medicaid products, the provider’s taxonomy code must align with AHCA’s Provider Master List (PML). We will not update the taxonomy code unless it is matched on the PML by the provider’s NPI number. This does not apply to the Medicare or Marketplace lines of business.

Please draft a letter on your company letterhead that includes the formal request to terminate. The letter should include your Tax ID, NPI, date of termination, and line(s) of business impacted by the termination. Documentation is required to process the termination. Please upload using the Supporting Document upload button. Please allow up to 30 days to process the termination request.

Select all lines of business the practitioner termination update applies to: required *

Please upload a copy of the W-9, dated within the least 12 months, using the Supporting Document upload button.

Please select whether you need to add or remove a website: required *