Professional Individual Professional Group Change Request Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Provider/Group Name and License Number in the designated fields. This information is crucial for identifying your practice.
3. If applicable, provide the New Provider/Group Name and both NPI numbers. Ensure accuracy as these identifiers are essential for processing changes.
4. Fill in the Previous and New Tax ID fields, along with the Effective Date of the New Tax ID if relevant. Remember, all Tax ID changes must be accompanied by a W-9 form.
5. Indicate any Hospital Admitting Privileges and their status (Active, Affiliate, etc.) by selecting Add/Delete options as necessary.
6. Complete sections regarding Specialty, Accepting New Patients, Handicapped Accessibility, and Language Spoken at Practice to ensure comprehensive updates.
7. Provide details about any Providers Leaving Practice, including Date of Leave and Reason for Leaving.
8. Finally, update Practice Address and Payment Address fields as needed. An authorized signature is required to finalize changes.

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