Physician and provider demographic change submission form

Physician and provider demographic
change submission form
The “Physician and provider demographic change submission form” (#M44539-A or M44539-B)
on the CD version of the Welcome Kit includes an outdated fax number.
The corrected form is enclosed, here, and also is available at UnitedHealthcareOnline.com >
Tools & Resources > Welcome Kit for New Physicians and Providers.
Physician and provider demographic change submission form
Please use this form for demographic changes or to update your NPI information.
Please ensure that ALL pertinent information is completed as we will be unable to process incomplete forms. Complete
all information pertaining to your practice. Fields with an asterisk* are required.
Please reference the Table on page 3. UnitedHealthcare and its affiliates/alliances are listed by Fax
Number/State. Please fax your completed form to the appropriate fax number.
Section I Group demographics
Practice/Organization Name
Current Tax ID (TIN)
National Provider Identifier
Date issued
/
/
Medicaid ID number
Please refer to Section III (page 2) of this fax form for taxonomy code definitions
*Please list your NUCC Taxonomy Code(s) 1) 2) 3) 4) 5) Basis for NPI (applies to organizations only, select only 1 per NPI):
 Provider Name  Tax ID only (entity whose name is in the W-9 form)  License Number  NUCC Taxonomy Code
 Place of Service Address  Department  Other (please explain)
 Please check here if you have multiple NPIs representing your Practice or Organization.
Refer to Section III (page 2) of this fax form.
Name of individual completing this form
Telephone (
)
Email
Section II Practice/Organization information changes
 The new tax ID number is:
*Effective
(please attach a copy of the W-9)
 We have moved. Our new address is effective
This new address is a:  Practice Address  Billing Address  Both Practice & Billing Address  Correspondence Address
Should this new address print in the directory?  Yes  No
New
Old
Telephone
Telephone
Fax
Fax
Email
Email
 We have changed our practice name to:
*Effective
 These physicians/health care providers have left our practice (please provide the effective date and reason for leaving):
 These physicians/health care providers have joined our practice effective _________________. (please attach a copy of the W-9)
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Section II continued
 Change pertains to all physicians/health care providers under the Tax ID (TIN):
 Specify physicians/health care providers affected by the change:
 We are closing our practice to new patients effective
 We are reopening our practice to new patients effective
 Check this box if you do not have a private office and only see patients at the hospital
Signature of Participating
Physician/Health Care Provider:
Date
Section III National Provider Identification - Requested information
We would like to capture the “basis” or reason for each NPI, if the organization has more than one NPI or has
sub-parts who have NPIs. Please use the grid below as a reference when filling in the “Basis for NPI” and Level
Information columns in the NPI Collection Grid below (page 3).
If the
Basis
for your
NPI is:
Then supply this
information in the
Level Information
column
C = Entity
whose name
is on the W-9
Tax ID and Name Filed If the organization or sub-part was enumerated strictly on the basis of the name
on W-9
associated with the Tax ID on the W-9 form, then use a “C” in the “Basis for NPI” column.
(You will need to indicate whether the Tax ID is a Social Security number or if it is an
employer identification number.) Place the Tax ID in the “Level Information” column.
D=
Department
Department Name
If the organization or sub-part was enumerated on the basis of a particular department,
provide the Department Name that the NPI was based on, and designate this with a “D”
in the “Basis for NPI” column. Insert the Department Name in the “Level Information”
column.
L = License
License Number and
State or (state code)
If the organization or sub-part was enumerated by License, provide the state or (state
code) and License Number that the NPI was based on, and designate this with an “L” in
the “Basis for NPI” column. Insert the License Number and state or state code) in the
“Level Information” column.
P = Place
of Service
Address
Place of Service
Address (Street, City,
State, ZIP +4)
If the organization was enumerated by place of service address, provide the street
address that the NPI was based on and designate this with a “P” in the “Basis for NPI”
column. Insert the Place of Service address in the “Level Information” column.
T= Tax ID
Number and
Provider Name
Tax ID and Provider
Name, where provider
is not the name on the
W-9, but bills using
this TIN
If the organization or sub-part was enumerated by Tax ID and Provider Name, where the
provider is not the name listed on the W-9, but uses this TIN, then designate this with
a “T” in the “Basis for NPI” column. Place the Tax ID in the “Level Information” column
and indicate whether the Tax ID is a Social Security number or if it is an employer
identification number.
X = Taxonomy
NUCC Taxonomy
Code
If the organization or sub-part was enumerated by a NUCC Taxonomy code, please
provide the Taxonomy Code that the NPI was based on and designate this with an “X” in
the “Basis for NPI” column. Place the NUCC Taxonomy Code in the “Level Information”
column.
O = Other
Specify details for
selecting ‘Other’
Provide any other basis for NPI in the “Basis for NPI” column and designate as “O”, with a
description of the basis for that NPI in the “Level Information” column.
M = Name
Provider Name
This is intended for use by physicians and allied health professionals (people providers).
Insert the name in the “Level Information” column.
Instructional information
page 2
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NPI collection grid
In the grid below please insert your Organization or Sub-Part NPI Number, Name, and Taxonomy Code(s)
associated with that NPI. Please indicate the basis for that particular NPI with the appropriate letter from the grid
above in the “Basis for NPI” column. Indicate the appropriate ‘Level Information’. If the number of NPIs exceeds this
sheet, please use the formatted spreadsheet (NPI Tracking Template) available on UnitedHealthcareOnline.com > Most
Visited > National Provider Identifier (NPI) > Multiple NPI Submission Fax Form to list your NPIs.
Taxonomy Code
(Codes associated
with each
individual NPI)
Organization /
Sub-Part Name
NPI Number
Basis
For NPI
Level
Information
NPI Issue Date
MM/DD/YYYY
Name of individual completing this form
Telephone (
)
Email
Please fax your completed form to the appropriate fax number below.
UnitedHealthcare
and its affiliates/alliances
Fax number
States (if applicable)
Mid Atlantic Health Plan
1-855-265-8686
MD, VA, WV, DC, DE,
Harvard Pilgrim Health Care Medica
1-855-264-7582
Neighborhood Health Partnership
1-855-263-9590
UnitedHealthcare Plan of the River Valley, Inc.
1-855-263-9590
UnitedHealthcare WEST
(Formerly known as PacifiCare Health Plan)
1-855-314-6844
UnitedHealthcare/Oxford
1-855-312-1651
NY, NJ, CT (excludes Upstate NY and Empire Health Plan)
UnitedHealthcare
1-855-773-3156
AL, AK, AR, AZ, CO, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MA
(New England), MI, MO, MS, MT, NC, NE, NH, NV, NM, OH, OK, OR,
PA, PR, RI, SC, SD, TN, TX, UNY(Upstate NY), Empire (Mkts 99318,
99309, 99310), UT, VI, VT, WA, WI, WY
M44539-A 9/11 © 2011 United HealthCare Services, Inc.
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