Provider File Update Request Form

Providers who need to make changes to the information contained within their provider file may use the Provider File Update Request Form. Instructions on completing the form are provided below. Please read over them prior to completing the form.

Provider Name and National Provider Identifier (NPI) Number

Block

Guidelines

1

If completing this request to update a business/facility, such as a Durable Medical Equipment (DME) facility, please indicate the name of the business/facility.  If completing this request to update a group/payee, such a physician practice and the associated individual providers, indicate the group/payee/practice name.

2

Indicate the National Provider Identifier (NPI) assigned under the provider name indicated in Block 1.

Physical Address Information

3

Physical address indicated must be a physical site of practice.  Home, P.O. Box and/or Lock Box addresses are not acceptable.  If individual providers associated to a group/payee have more than one site of practice enrolled as part of one group/payee number, changing the physical address of the group/payee is not required when updating providers within the group/payee.

3A

Select “yes” or “no” to reflect if the physical address of the group/payee should be updated.  If multiple sites of practice are associated to one group/payee, a central location may be indicated as the physical address of the group/payee.

4

Indicate the business phone number to be used to contact the person (s) such as an office manager or the associated provider (s).

5

Indicate the business fax number to be used to contact the person (s) such as an office manger or the associated provider (s).

Payee Information

6

Payee address indicated will be used specifically for mailing Explanation of Payment (EOP) Forms, but may also be used for mailing general correspondence.  P.O. Box and Lock Box addresses are acceptable.  This address must be consistent for all provider NPI numbers given in Block 1 and on Page 3.

7

Indicate the phone number to be used to contact the person (s) who deal with the payments rendered, electronic deposits, etc.

8

Indicate the fax number to be used to contact the person (s) who deal with the payments rendered, electronic deposits, etc.

9

Mailing address indicated will be used specifically for mailing 1099 Forms, but may also be used for mailing general correspondence.  P.O. Box and Lock Box addresses are acceptable.  This address must be consistent for all providers given in Blocks 1 and 13.

10

Indicate the phone number to be used to contact the person (s) who deals with the 1099s, etc.

Notification Information

11

Options are offered to allow providers to receive Alerts, Provider Insiders and Provider Notices via e-mail, facsimile or paper.  Please indicate how your office would prefer to receive such documents.  Selections are shown in blocks 11.A. through 11.C.  Only one option may be chosen.

11A

Providers who indicate paper will receive Alerts, Provider Insiders and Provider Notices via regular mail.

11B

Providers who indicate E-mail will receive Alerts, Provider Insiders and Provider Notices in an Acrobat (PDF) format via e-mail.  These documents will be forwarded to the e-mail address indicated in Block 12.

11C

Providers who indicate Fax will receive Alerts, Provider Insiders and Provider Notices via fax.  These documents will be faxed to the fax number indicated in Block 5.

12

Indicate the E-mail address to be used if selecting E-mail to receive Alerts, Provider Insiders and Provider Notices.

  1. Business/Group/Provider Name: 

  1. National Provider Identifier (NPI): 

Please indicate only one provider name and NPI in the spaces above.  Please ensure the number indicated is assigned to the provider whose name is indicated.  If additional provider files need to be updated with the information indicated on this form, please indicate the provider names and NPI Numbers on page 3.

  1. Physical Address:
Street Address: 
          City:  State:  Zip Code: 
   3A. Do you intend for EDS to change the physical address currently on file for the group/payee/practice?

          Yes:        No: 

  1. Business Phone: 
  1. Business Fax:    
  1. Payee Address:
Street Address: 
          City:  State:  Zip Code: 
  1. Payee Phone:                                               
  1. Payee Fax:         
  1. Mailing (DBA) Address:
Street Address: 
          City:  State:  Zip Code: 
  1. Mailing (DBA) Phone:
  1. Alerts/Insider/Notice: (Please check one option below:)

          11.A.) Paper         11.B.) E-mail     11.C.)  Fax     

  1. Email Address:  

I certify that, to the best of my knowledge, the information supplied in this request is accurate, complete and is hereby released to EDS for the purpose of updating the Alabama Medicaid enrollments assigned to the named provider (s).

Signature

Signature Date

Print Name of Person Signing Form

Indicate Title of Person Signing Form

(Signature must be hand written and must be the signature of personnel authorized to make changes for the named provider (s). Black ink is required.)

Additional Provider Names and NPIs

Indicate additional provider name (s) and NPI number (s) below and attach additional sheets if necessary. The provider name (s) and NPI number (s) indicated below must be associated to the group/payee NPI number indicated in Block 2:

Provider Name Provider NPI Number

Mailing Instructions

Print a copy of the completed form and mail or fax it to the Provider Enrollment team.

Note: Please print a copy of the Provider Update Request form for your records.

If you have any questions concerning this form, please feel free to contact us at 1-888-223-3630 (in Alabama) or 334-215-0111 (outside of Alabama).