Form 110 - Provider Change Of Data
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1Provider Change of Data Form
Please use this form to indicate changes in your data. Complete applicable sections only. Please mail or fax (501-378-2465) the completed form
with supporting documents to: Provider Enrollment, PO Box 2181, Little Rock, AR 72203. If payment to a clinic or group is required, please
complete an Authorization for Clinic Billing form. Practitioners wishing to use an Employer Identification Number (EIN) for payment must
submit verification of EIN (Letter 147C, CP 575 E, or tax coupon 8109-C). Please type or print.
Name ______________________________________________________________ NPI _____________________________
(First, MI, Last)
(Attach copy of NPI verification from NPPES)
Doing Business As _________________________________ ABCBS# __________________________________________
Change Effective Date ______________________________ Medical Records Fax # _______________________________
Date of Birth _________________ Degree _____ Male ___ Female ____ US Citizen? ___ SSN ____________________
Specialty ____________________________________ Secondary Specialty ______________________________________
English
Primary Language _____________________________ Secondary Languages _____________________________________
Handicapped Accessible? _______________________ TTY Services? ___________________________________________
AR License/Certification # ________________________________ Issue Date ___________ Expiration Date ____________
(Attach copy of license)
Other License/Certification # _____________________ ST _____ Issue Date ___________ Expiration Date ____________
(Attach copy)
DEA # ______________________________________ ST _____ Issue Date ___________ Expiration Date ____________
Email Address ________________________________________________________________________________________
Primary Contact Person ____________________________________ Title _______________________________________
PHYSICAL LOCATION INFORMATION - Must have a street address – PO Boxes are not acceptable
Practice Location Address _____________________________________________________________________________
__________________________________________________________________________________________________
Phone # to be used for Patient Appointments _________________________ Fax # _______________________________
CORRESPONDENCE INFORMATION - For notifications, newsletters, credentialing updates, etc.
Correspondence Address _____________________________________________________________________________
__________________________________________________________________________________________________
Correspondence Phone # ________________________________________ Fax # _______________________________
PAYMENT INFORMATION - If payment to a clinic or group is required, please complete the Authorization for Clinic Billing form.
Are you incorporated? _______________ Payment EIN _____________________________________________________
(Attach IRS verification of EIN)
Payment Name _____________________________________________________________________________________
Payment Address ___________________________________________________________________________________
__________________________________________________________________________________________________
Payment Phone # ______________________________________________ Payment Fax # _______________________
_________________________________________________________________________________________________________________
Print Name of Individual Practitioner
Signature __________________________________________________________________________ Date __________________________
(Individual Practitioner- NO STAMPS OR DIGITAL SIGNATURES)
PNO 0805
FORM 110
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