Care Provider Demographic Information Update

1 Doc#: PCA-1-010588-04302008_08212018 DRG#: 00077401 care Provider Demographic Information Update The My Practice Profile tool on Link lets you view, Update and attest to the care Provider Demographic Information UnitedHealthcare members see for your organization. Use the tool to make Demographic changes just one time, in one place and get those updates into our systems more quickly. You can find instruction about updating your Information at If you can t Update Demographic Information online, use this form for a single care Provider practitioner Update . For practices with two or more care Provider practitioners, please use the Group/Organization Demographic Information Update form at Incomplete forms will not be processed.

2 UnitedHealthcare uses current data and the updates you provide to publish accurate care Provider directories. By submitting this form, you are confirming that these are the only changes needed at this time. Fields with an asterisk (*) are required for practitioners providing care under all UnitedHealthcare plans. If additional space is required, please include a separate roster with this form. A W-9 form form is required when adding new tax ID numbers and making name changes. Index: Section I Single care Provider and Group/Organization Association Information Section II Adding or Updating a Single care Provider Section III Maintaining Taxpayer ID Numbers, Addresses and Contact Information Section IV National Provider Identifier (NPI) Definitions and Requirements Section V Sign and SubmitSection I Single care Provider and Group/Organization Association Information * care Provider name: Last: First: MI: Suffix: This is a name change.

3 Attach a copy of the W-9 form for name changes. Previous care Provider Name: Effective Change Date (MM/DD/YYYY): *Tax ID Number (TIN): Name of group or organization associated with this care Provider /TIN: Effective Change Date (MM/DD/YYYY): Group/Organization National Provider Identifier (NPI) Number Please refer to Section IV for details about NPI number requirements. Is the group/organization an atypical Provider ? Yes. NPI is not required. No. *Complete the following NPI Information :Doc#: PCA-1-010588-04302008_08212018 DRG#: 00077402 NPI Number: NPI Number Taxonomy Code: NPI Number Issue Date (MM/DD/YYYY): Basis for NPI Number: NPI Number Level of Information : Section II Adding or Updating a Single care Provider Remove the following care Provider (all questions are required)Name: NPI: TIN: Effective Date (MM/DD/YYYY): The care Provider is leaving the group/contract TIN for the following reason.

4 care Provider Retired care Provider Deceased care Provider Left Group care Provider Not Affiliated with TIN/Contract Provider Left Service Area Voluntary Leave of Absence Incorrect Data Other (Personal, Sabbatical, etc.) For PCPs no longer associated with a TIN, UnitedHealthcare will reassign members to the listed care Provider when available: If we aren t able to assign to your selected care Provider , UnitedHealthcare will identify an acceptable replacement. Add the following care Provider (all questions are required)When adding a new care Provider , answers to all questions are required. When updating a care Provider s Information , fill out only the updated Date of birth (MM/DD/YYYY): 2.

5 Gender: Male Female Unknown3. Does the care Provider have a Medicare identification number? Ye s : No 4. Does the care Provider have a Medicaid identification number? Ye s : No 5. Is the care Provider a primary care Provider (PCP) or specialist? PCP Specialist6. Is the care Provider hospital-based operating solely in a hospital? Ye s No7. Is the care Provider a hospitalist? Ye s No 8. Does the care Provider have hospital affiliations? Ye s No If Yes, list the hospital names next to the type of admitting privilege, which indicates the hospital affiliation type. Active (AC): Active Admitting (ACT): Active Non-Admitting (NAC): Adjunction Staff (ADJ): Admitting (ADM): Affiliate (AFF): Doc#: PCA-1-010588-04302008_08212018 DRG#: 00077403 Assistant Adjunction (ATA): Assistant Attending (ACA): Associate (ASC): Attending (ATT): Clinical Privileges (CLP): Consulting (CON): Consulting Admitting (CN): Consulting Non-Admitting (NCN): Courtesy (COU): Courtesy Admitting (CT): Courtesy Non-Admitting (NCT): Deferred (DAP): Honorary (HON): Non-Admitting (NAN): Provisional Non-Admitting (NPR): Unknown (UNK): 9.

6 Remove the following hospital affiliations (hospital names): 10. Is the care Provider accepting UnitedHealthcare members as new patients? Ye s No care Provider isn t accepting UnitedHealthcare members as new or existing Does the care Provider accept new Medicaid patients? Ye s No care Provider isn t accepting new or existing Medicaid patients. 12. Does the care Provider accept new Medicare patients? Ye s No care Provider isn t accepting new or existing Medicare care Provider s email address: Not applicable a. Is this email address for an individual care Provider or the email address for an office location?

7 care Provider Location b. List this email address in the care Provider directory? Ye s No14. care Provider s website: Not applicable a. Is this an individual care Provider s website or the website for an office location? care Provider Location b. List this website in the care Provider directory? Ye s No15. Is the practitioner an Indian Health Service Provider ? Ye s No16. Does the care Provider have telehealth service capability? Ye s NoDoc#: PCA-1-010588-04302008_08212018 DRG#: 0007740417. National Provider Identifier (NPI) Number Please refer to Section IV for details about NPI number requirements Is the care Provider an atypical Provider ?

8 Yes. NPI is not required. No. *Complete the following NPI Number Information :NPI Number: NPI Number Taxonomy Code: NPI Number Issue Date (MM/DD/YYYY): Basis for NPI Number: NPI Number Level of Information : 18. care Provider s primary specialty: a. Is the care Provider board-certified for this specialty? Ye s No19. care Provider s secondary/sub-specialty: Not available20. care Provider s expertise (when applicable) with individuals: With physical disabilities With chronic illness With HIV/AIDS With serious mental illness Who are homeless Who are deaf or hard-of hearing Who are blind or visually impaired With co-occurring disorders Who are transgender Other specialties: 21.

9 care Provider s Primary degree: Secondary degree: 22. care Provider s board certifications: 23. care Provider s state licenses (please add dates as MM/DD/YYYY): State: License: Effective Date: Expiration Date: State: License: Effective Date: Expiration Date: 24. For mid-level care providers, list the supervising physician s Information . Name: Specialty: Mid-level care providers have a medical degree, but are not physicians. A mid-level Provider can diagnose and treat patients under the supervision of a licensed physician or independently as allowed by state law and Does the care Provider have a Drug Enforcement Administration (DEA) registration number?

10 Ye s : Expiration Date (MM/DD/YYYY): NoDoc#: PCA-1-010588-04302008_08212018 DRG#: 0007740526. care Provider cultural competency training dates (MM/DD/YYYY) a. Communication Skills Interpreter Services (CIS) Effective Date: Expiration Date: b. Communication Skills Language Availability (CLA) Effective Date: Expiration Date: c. Communication Skills Soft Skills (CSS) Effective Date: Expiration Date: d. Financially Challenged Patients (FCP) Effective Date: Expiration Date: e. Homeless (HL) Effective Date: Expiration Date: f. LGBT Communities (LGB) Effective Date: Expiration Date: g.