Organization Maintenance Change Request FormOrganization Maintenance Change Request Form Rev. 04.16.2016.1 Change Organization NPI or Tax ID Note: To change an existing identifier,
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Organization Maintenance Change Request Form
Rev. 04.16.2016.1
Instructions
1. Complete the Organization Information section.
2. (Optional) To change your organization’s NPI or tax ID, complete the Change Organization NPI or Tax ID
section.
› Availity allows only one NPI for each organization. To associate additional providers to your organization
for express entry on transactions, go to My Account | Express Entry in the Availity Web Portal.
› If your tax ID has changed but your organization has not changed ownership, enter your new tax ID in the
Availity Web Portal instead of completing this form. Go to Account Administration | Maintain
Organization, and enter the new tax ID in the Tax ID field on the Organization Information page.
3. (Optional) To change your organization type, complete the Change Organization Type section.
Important: If your organization has contracts with payers in more than one state (geographic location),
contact Availity Client Services at 1.800.282.4548 to update your organization’s account.
4. Have the form signed by your organization’s Administrator and witnessed by a person not named on this form.
5. Return the completed, signed form to Availity:
Fax Mail
904.470.2187 Attn: Availity Security
Availity, L.L.C. Registration Department PO Box 550857 Jacksonville, FL 32255-0857
Organization Information (all fields required as currently on record with Availity)
Organization Name: Customer ID:
City: State:
Administrator Last Name:
Organization Maintenance Change Request Form
Rev. 04.16.2016.1
Change Organization NPI or Tax ID
Note: To change an existing identifier, complete two rows—one to delete the original identifier, and one to add the new identifier.
Add Delete
Identifier Type (select one)
Enter the NPI or Tax ID
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Change Organization Type
To change your organization type with Availity, select the check box next to the new organization type below. Be careful when requesting this change. Not all organization types receive access to the same features in Availity
Ambulatory Surgical Center Hospital Non-Physician Provider
Billing Service IPA Pharmacy
Durable Medical Equipment Laboratory Physician Practice
Home Healthcare Long-Term Care Facility Urgent Care
Hospice Multi-Physician Practice
Signatures
Administrator
I, , the undersigned Administrator, do hereby attest to the accuracy and completeness of the information provided by the organization in this document and attest that I have the authority to, and hereby do, make these changes on behalf of the organization.
Signature:
Date:
Witness
Name:
(print or type)
Signature:
Date:
(must match Administrator signature date)
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