Facility Contact Information Change Form: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Facility Contact Information Change Form with DocHub

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Facility Contact Information Change Form in our editor.
Begin by filling out Section 1, which includes your Facility Name and Provider Billing NPI Number. Ensure you also provide the SSN or Tax ID Number, noting that a separate form is required for each Tax ID.
Indicate the necessary changes by checking the appropriate boxes for new contacts such as CEO/Administrator, CFO, Business Office Manager, Quality Manager, or any other contact change. Don’t forget to specify the effective date of these changes.
Proceed to complete the relevant sections (2-5) based on the new contact roles. For each section, enter both former and new names along with their phone numbers, fax numbers, and email addresses.
In Section 6, if applicable, provide details for any other contact changes following the same format as previous sections.
Finally, sign and print your name in the designated area at the end of the form before sending it via fax or mail as instructed.

Start using our platform today to easily manage your facility's contact information changes!

See more Facility Contact Information Change Form versions

We've got more versions of the Facility Contact Information Change Form form. Select the right Facility Contact Information Change Form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (43 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

Is it safe to sign my Facility Contact Information Change Form electronically?

You should use only trustworthy software solutions with strong security compliance to approve your paperwork electronically. DocHub is just the type of editor you need! It stores data on Amazon Web Servers and complies with all required security standards and eSignature laws, so it’s a trustworthy way to electronically sign your Facility Contact Information Change Form or other paperwork using this tool.

How to complete Facility Contact Information Change Form online free of charge in 2024?

With a swift editing system like DocHub, you do not need anything but a browser and connection to the internet to edit your Facility Contact Information Change Form online easily. Upload your document or find the relevant form in DocHub’s catalog, open our editor with one click, and complete it digitally. To revise your forms at any time, sign up a free account with DocHub.

How to cancel BC Health Insurance?

To request a cancellation, submit a Coverage Cancellation form (HLTH 217) (PDF, 137KB) to Health Insurance BC (HIBC), or submit a written request including your group number, employee account number(s) and name(s), and all the information required on the form. Cancelling Members Benefits - Province of British Columbia gov.bc.ca gov health msp administer gov.bc.ca gov health msp administer

Can doctors opt out of MSP?

Enrolled physicians may choose to be opted-in or opted-out. Opted-in physicians are physicians who are enrolled in MSP under Section 13 of the Medicare Protection Act and who elect to bill MSP directly for insured services provided to MSP beneficiaries. Enrolment - Province of British Columbia - Gov.bc.ca gov.bc.ca gov health msp physicians gov.bc.ca gov health msp physicians

What is a MSP facility number?

MSP Facility Numbers are issued to qualifying facilities, based on the physical location of the facility. Eligible Physicians are those practitioners who are responsible to pay for some or all of the lease, rental, or ownership costs of the community-based office that has been issued an MSP Facility Number.

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

What happens if you dont pay MSP BC?

If you have a balance owing after the due date, your account will become overdue and collection action will begin. Collection action may include: notifying the Canada Revenue Agency to apply money owing to you to your health fee balance. requiring your employer to deduct money from your paycheque. Overdue Payments - Province of British Columbia - Gov.bc.ca gov.bc.ca accessing-health-care pay o gov.bc.ca accessing-health-care pay o

How do you quit MSP?

If you do not want to participate in B.C.s provincial health care programs, you must complete and sign an Election to Opt Out statement and submit that statement to the Ministry of Health each year. Contact Health Insurance BC (HIBC) to obtain an Election to Opt Out form. Opting Out of Medical Services Plan (MSP) Coverage Gov.bc.ca managing-your-msp-account Gov.bc.ca managing-your-msp-account

How can I cancel my MSP?

If you do not want to participate in B.C.s provincial health care programs, you must complete and sign an Election to Opt Out statement and submit that statement to the Ministry of Health each year. Contact Health Insurance BC (HIBC) to obtain an Election to Opt Out form.

Facility Contact Information Change Form 2026

Here's how it works

How to use or fill out Facility Contact Information Change Form with DocHub