Clinic Name: Current name of clinic, hospital or other facility

Tax ID: The nine-digit identification number used by the Internal Revenue Service in the administration of tax laws for this provider or practitioner

Billing NPI: The unique 10-digit identification number for each covered health care providers. List all applicable NPIs.

Practitioner Name (if applicable): Name of each practitioner that has a change in information

Practitioner NPI: If applicable, the unique 10-digit identification number assigned each to health care practitioner with a change in information

Effective Date: Effective date of change

Reason for Change: Select the item that best describes the reason for change from the drop down list

Change Request: Description of change being reported(for example: practitioner name change, address change, status change, adding OB services, etc)

Completed by: Name of the individual completing this form. Individual must be authorized to represent the provider office for enrollment with health insurance payers

Email Address: Email address associated with contact

Phone: Telephone number associated with contact