Verify enrollment 2025

1. Click ‘Get Form’ to open the verify enrollment document in the editor.
2. Begin by entering the effective date of any changes at the top of the form. This ensures that your updates are recorded accurately.
3. Fill in the Provider Tax ID number, which is essential for identification purposes.
4. Select whether you are adding a new provider or changing existing provider information by checking the appropriate boxes.
5. Complete all required fields under 'Add New Provider to Network' or 'Change Existing Provider Information', including Tax ID changes, address updates, and contact information.
6. If applicable, list additional practice locations and ensure all details are filled out correctly for each location.
7. Attach any required documents such as HCFA or UB forms, ensuring they are complete before submission.
8. Finally, provide your name, email, phone number, and signature at the bottom of the form to finalize your request.

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