Demographic Change Form (Page 2 of 3) in pdf

Demographic Change Form Page 2

Changing/Adding Business or Birthing Center Name:

Business NEW name ___________________________________________________

Birth Center NEW name __________________________________________

License #: __________

Previous Name: __________________________________________________________

Address Change:

New Mailing Address

_________________________

(where you want insurance correspondence and payments delivered):

City: _____________________________ County: _________________ State: _____ ZIP:____________

Physical Address

: _______________________________________

(if mailing address is a PO Box)

City: _____________________________ County: __________________ State: _____ ZIP:___________

Previous Address: ____________________________________________________________________

City: _____________________________ County: __________________State: ______ZIP:___________

Tax Identification / NPI Change:

New EIN Number: _________________________ Previous EIN or SSN Number: __________________

New Individual NPI #: ________________________ Previous NPI #: __________________________

New Group Tax Identification Number (EIN): ________________________

Group/Business NPI#: ____________________

Contracts:

Please list any insurance companies that you are currently in network with: ________________________

____________________________________________________________________________________

Other:

Additional information you would like us to know: ____________________________________________

____________________________________________________________________________________

Page 2 of 3

Larsen Billing Service – Demographics Change Form

Revised 10/1/2014

Demographic Change Form Page 2