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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'From' field with the name of the contact person and enter the date in MM/DD/YY format.
- For individual practitioners, provide your Type 1 National Provider Identifier and State license number. If you are adding an individual to an existing group, ensure to fax a group change form.
- For allied providers, complete the same fields as above but include your Type 2 NPI and Tax identification number.
- If you are part of a professional group practice, repeat the process for entering your details including Type 2 NPI and Tax ID.
- Ensure all required fields marked with an asterisk (*) are filled out accurately before submission.
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