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Provider Demographic Updates: Behavioral Health Facility

Behavioral Health Facility

Back to primary service type selections

Please Select the Demographic Update Requested required * Address Update - Correspondence Address Address Update - Pay to Address Address Update - Practice Location Address Address Update - W-9 Address CLIA Update Contact Information - Credentialing Contact Update Contact Information - Office/Primary Contact Information Update Group Name Change Pharmacist CE Status Update - Ambetter Only Pharmacist Board Certified Protocol Status Update - Ambetter Only Provider/Practitioner Name Change TAX ID Change Telephone Number Change OTHER - Enter Specific Request in the Other box at the bottom of the form.

Error: Demographic Update Selection is required.

Please select Provider type required * BHSO - Behavioral Health Service Organization ASAM Certified BHMSG - Behavioral Health Multi-Specialty Group CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center CCBHC - Certified Community Behavioral Health Clinic PRTF - Psychiatric Residential Treatment Facility Residential Crisis Stabilization Unit

Error: Provider is required.

Please populate the below.

Provider Name *

Error: Provider Name is required.

NPI *

Error: NPI is required.

License Number *

Error: License Number is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

Line of Business (Please select all that apply) required * Medicaid Medicare Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Practice Location Address Update

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Directory Inclusion choice is required.

Correspondence Address

Correspondence Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Correspondence Address is required.

City *

Error: Correspondence City is required.

State *

Error: Correspondence State is required.

Zip Code *

Error: Correspondence Zip Code is required.

County *

Error: Correspondence County is required.

Phone Number *

Error: Correspondence Phone Number is required.

Fax Number *

Error: Correspondence Fax Number is required.

CLIA Number *

Error: Correspondence CLIA Number is required.

CLIA Expiration *

Error: Correspondence CLIA Expiration is required.

Pay To Address

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: Pay To State is required.

Zip Code *

Error: Pay To Zip Code is required.

W-9 Address

Street Address *

Error: W-9 Address is required.

City *

Error: W-9 City is required.

State *

Error: W-9 State is required.

Zip Code *

Error: W-9 Zip Code is required.

Your Contact Information

Primary Contact Name *

Error: Primary Contact Name is required.

Email *

Error: Primary Contact Email is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Email *

Error: Credentialing Contact Email is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information

Other (Specific Request)

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