STANDARDIZED PROVIDER INFORMATION CHANGE FORM

STANDARDIZEDPROVIDERINFORMATIONCHANGEFOR MCOMPLETE ALL APPLICABLE INFORMATION AND UTILIZE SUBMIT BUTTON FOR NEW PROVIDERS,CONTRACTUALMODIFICATIONS,OR CREDENTIALING CHANGES1of 2*2. PROVIDER INFORMATION :*Section requiredLast Name:First Name:MiddleInitial: PROVIDER Former Name(if applicable):Gender: Male FemalePrimary Specialty:INDNPI:INDTAX ID:EPSDT (If applicable) : Yes NoAccept Medicare & Medicaid: Yes NoHospital Accreditation:Hospital Affiliation 1:2:3:Board Certification 1:2:3:Language 1:2:3: PROVIDER Type: PCP Ancillary BehaviorHealth Facility LTSS SpecialistAddress Line 1:Address Line 2:City:State:County:Zip Code: PROVIDER Email Address:3.

standardized provider information change form complete all applicable information and utilize ‘submit’ button below. incomplete submissions may be returned unprocessed. not for new …

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