Provider Change Notification Form Please complete all sections. You must have JavaScript enabled to use this form. Information Changing Practice Billing TIN Other Group NPI Number Group Medicaid Number Location Code Medicare Number List in Directory Yes No Age Limit None 0-17 18+ Yrs 21+ Yrs Hospital Based Yes *By checking yes, you are stating that the provider practices solely in the hospital setting at SJHS and members are referred to the facility and not directly to the provider. Hospital based providers will not be listed in the provider directory. No Contact Person Email Provider Data New Information Previous Effective Date Tax ID Number Specialty Practitioner's Name Practitioner E-mail Practice Name Practice Address City, State, Zip Practice Manager Phone/Email EMR Software/Version Phone Number Fax Number Office Hours Accepting New Patients New Information Yes No Previous Information Yes No Billing Information Billing Data New Information Previous Information Effective Date Billing Company Billing Address City, State, Zip Phone Number Fax Number Remit Information Remit Data New Information Previous Information Effective Date Remit To Name Remit Address City, State, Zip Comments Submit
