Demographic Change Form printable pdf download

Demographic Change Form

EMOGRAPHIC

HANGE

ORM

Note: It is not necessary for you to complete this form if changes have to do with your phone/fax number or your email

address. Such information can be sent directly to your biller.

Name on existing account: ___________________________________________________

Please fax this form to your biller along with a copy of your current midwifery license and W-9 showing all updates.

Changes on the Account

Please mark all that apply

 Provider name  Business name  Credentials

 NPI number

 Physical and/or mailing address

 Adding a provider who will use the existing tax ID number

 Adding a provider who will use a new tax ID number

 Individual Tax Identification number (SS#)

 Group Tax Identification Number (EIN)

Fill out sections that apply to changes only

Effective Date of Change: ___________________________

Additional Provider:

Provider Name (no nicknames): ________________________________________________________

Credentials: ____________

Date of Birth: ____________

License Number: ________________

NPI: __________________________________

Tax ID: _______________________________

Phone Number: ______________________________ Fax Number: __________________________

Email Address: _________________________________

Address (no PO Boxes): ______________________________________________________________

City: ________________________ State: ________ Zip: _________________

Le ga l P a rtne r

Em ploye e or Inde pe nde nt C ontra ctor

Relationship to existing LBS account:

Ye s

Do you have a CLIA license or waiver?

If yes: CLIA #:___________________ Must send copy to LBS in order for us to bill for labs.

Add na m e to e xis ting form s

W ill not ne e d ne w form s

Forms:

Other Information: ____________________________________________________________________

___________________________________________________________________________________

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Larsen Billing Service – Demographics Change Form

Revised 10/1/2014

Demographic Change Form