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: