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Provider Demographic Information Change Request Form

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The document is a Provider Demographic Information Change Request Form used by healthcare providers to update their demographic and billing information. It includes sections for current provider details, types of changes requested (such as adding or changing tax identification numbers, addresses, or specialties), and requires the submission of a W-9 form for tax ID updates. The form must be completed and submitted via fax or email, with a processing time of up to 45 days.

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See more Provider Demographic Information Change Request Form versions

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Versions	Form popularity	Fillable & printable
2021	4.9 Satisfied (46 Votes)
2013	4 Satisfied (36 Votes)
2009	4.7 Satisfied (42 Votes)

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