Dhs 3535a 2025

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The document is a Provider Demographic Change Form from Blue Cross and Blue Shield of Minnesota, intended for healthcare providers to update their contact information, hospital affiliations, and office hours. It outlines the necessary details to be filled out for changes, including legal names, addresses, phone numbers, and NPI numbers. The form must be submitted via fax or mail, and it includes sections for both old and new information.

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Click ‘Get Form’ to open the dhs 3535a in the editor.
Begin by entering your Tax ID number and the effective date of change at the top of the form. This information is crucial for processing your request.
Fill in the 'Old Information' section with your current legal name, NPI/UMPI number, and DBA. Ensure that all addresses (mailing, physical, billing) are accurately listed.
In the 'New Information' section, provide updated details as necessary. If any address remains unchanged, simply indicate that in the respective fields.
Complete the hospital affiliations section by listing relevant details about your hospital connections and their operating hours.
Finally, sign digitally in the 'Person Completing Form' section and provide your contact information before submitting.

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