Provider Information Update Form
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1
2Fax Number to: 866- 561-9260
Email to:
Phone Number: 866-610-8514
Mail to: ConnectiCare, Inc.
Credentialing Department
175 Scott Swamp Road
Farmington, Connecticut 06034
Provider Information Update Form
Provider Name:
Type of Provider:
Provider Changes
(Please check the box below)
□
□
Adding / Removing a practice address (A)**
Provider is not accepting new patients, if checked
panels will be closed for all contracted lines of
business (commercial, exchange & Medicare
□
□
Removing a provider (C)
Correcting an existing correspondence address (B)
□
Correcting an existing billing address (D)
Note**: When adding or changing the Practice Address information, please also enter the Correspondence and Billing Address
information below.
Note: ConnectiCare will endeavor to update its records within thirty (30) days of receipt of the completed paperwork.
Please be sure to update your CAQH application with all changes submitted to
ConnectiCare.
A. ADDING / REMOVING A PRACTICE ADDRESS
Practice Address to be removed
New Practice Address
Street Address:
Street Address:
City:
State:
Zip:
City:
State:
Zip:
Telephone Number:
Fax Number:
Telephone Number:
Fax Number:
Office Hours:
Federal Tax ID #:
NPI #:
Federal Tax ID #:
NPI #:
Effective Date of Practice Address Change:
_/ _/
Page 1
January 2016
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Parent category: Business