Looking for a Change Of Information Form Templates? Download it for free!

Mvp Form 0097 - Provider Change Of Information Form For Contracted And Non-Contracted Group Or Individual Provider - Mvp Health Care

Provider Change of Information

for Contracted and Non-Contracted Group or Individual Provider

MVP makes every effort to ensure a provider’s information in our systems is accurate. If you or your practice have

changes in demographic and/or participation status, it is important to promptly notify MVP.

MVP must be informed if:

• There is a change in demographic information.

• There is an update to payment information such as Tax ID or remittance advice.

• There is a specialty or category change (i.e., primary care physician or specialist).

• A panel is being closed

• A provider has an upcoming leave of absence.

• A provider is leaving the network.

Instructions for Completing the Provider Change of Information

Provide all required information on the Provider Change of Information form that applies to your request.

If the change applies to multiple providers in a group practice, include a roster of all providers, NPIs, and specialties.

For multiple address changes, submit a copy of the form for each address change and attach a roster.

If a provider is changing their name or license number, submit a copy of the license with the Provider Change of Information form.

If your Tax ID number or Remit Name are changing, you must submit a copy of an updated W-9, Request for Taxpayer Identification

Number (TIN) and Certification.

The Authorization/Contact information section is required and must be completed. MVP may contact you with any questions.

Failure to complete this section may result in the change being processed inaccurately or not at all.

Update the provider’s CAQH application with any changes you submit to MVP.

Submit a separate form for each address addition or change. See Section 1 of the form.

For new address or changes, a roster of providers affected by the change, including NIP and specialty, must accompany the

completed form when submitted to MVP.

10. For new Tax Identification Numbers (TIN) or new TIN Name, a W-9 Request for Taxpayer Identification Number (TIN) and

Certification must accompany the completed form when submitted to MVP. See Section 5 of the form.

11. Return the completed Provider Change of Information form and any required documentation to MVP at the appropriate email

listed below. The completed form must include an Authorized Signature and Contact information. See Section 6 of the form.

East/Massachusetts Region

Central/Mid-State/Southern Tier Region

Rochester Region

Mid-Hudson Region

Vermont Region

Questions?

Contact MVP Professional Relations at .

MVPform0097 (02/2017)

Mvp Form 0097 - Provider Change Of Information Form For Contracted And Non-Contracted Group Or Individual Provider - Mvp Health Care