PROVIDER CHANGE FORM 24-Hour Crisis Care & Service Enrollment - 877.685.2415 Business & Administrative Matters - 866.998.2597 TrilliumHealthResources.org NOTE REQUIRED Items and REQUESTED ATTACHMENTS. Complete other information only if there is a change. PROVIDER INFORMATION: (REQUIRED) Provider Name Effective Date mm dd yyyy Medicaid Provider # NPI # TYPE OF CHANGE New Main Contact: (Attach copy of up-to-date W-9) Street Address County City State Zip+4 Phone # Fax # Email Office Hours Remove Main Contact: Street Address County City State Zip+4 Phone # Fax # Email Office Hours Add NEW Office (Site) Location: Street Address County City State Zip+4 Phone # Fax # Email Office Hours PREVIOUS Office (Site) Location : Street Address County City State Zip+4 Phone # Fax # Email
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Trillium - Provider Change Form · 2019-06-09 · Page 2 of 4 Trillium - Provider Change Form Revised 12.10.15 Remove Office (Site) Location : Street Address County City State Zip+4
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PROVIDER CHANGE FORM
24-Hour Crisis Care & Service Enrollment - 877.685.2415Business & Administrative Matters - 866.998.2597 TrilliumHealthResources.org
NOTE REQUIRED Items and REQUESTED ATTACHMENTS.
Complete other information only if there is a change.
New Billing Location: (Attach copy of your up-to-date W-9)
Street Address County
City State Zip+4
Phone # Fax #
Email
Office Hours
PREVIOUS Billing Location:
Street Address County
City State Zip+4
Phone # Fax #
Email
NPI : (Attach copy of NPPES reflecting NPI change)
Previous NPI New NPI
Individual Provider Name: (Attach copy of new license or certification reflecting name change)
Previous Full Name
New Full Name
Individual Provider Tax Name: (Attach copy of new license or certification reflecting name change)
Previous Tax Name
New Tax Name
Individual Tax ID: (Attach copy of your up-to-date W-9) (**Please note if you are changing your tax ID number, you will need to reapply as a new provider.**)
Previous Tax ID New Tax ID/SSN
Change in Bed Capacity: (Attach state license reflecting bed capacity change; please update Registry of Unmet Needs inProvider Direct)
From # Beds To # Beds
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Trillium - Provider Change FormRevised 12.10.15
Change in Provider Specialty: (Attach new license and letter requesting new specialty)
New Specialty
New Specialty
New Specialty
Terminate Medicaid Participation: (Attach request for termination on your letterhead)
Due to Change in Ownership
Due to Other (Describe)
Delete a Clinically Licensed Practitioner: (MD, PA, FNP, LCSW, etc.)
Individual’s Name Date of Birth
Medicaid Provider # Effective Date End Date
E-mail Address
Please list the specialties of this clinician that will no longer be provided and/or cannot be provided by another clinician
(Email address required for credentialing-related communication)
CABHA Affiliation - Change in Key Personnel: (Check “Add” or “Delete” and complete information)
ADD
Name
Position Effective Date
mm dd yyyy
DELETE
Name
Position Effective Date
mm dd yyyy
Deletion of Services Provided: (List each service code and the end date)
Service Code End Date mm dd yyyy
Service Code End Date mm dd yyyy
SIGNATURE PAGE IS REQUIRED (PAGE 4)
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Trillium - Provider Change FormRevised 12.10.15
SIGNATURE (REQUIRED)
I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for the denial or termination of participation as a provider.
Signature of Authorized Person Date
Printed Name Title
E-Mail Fax: USPS
Ty Martin Fax (252) 215-6883 Trillium Network Operations
Once this proposed change is reviewed and approved by Trillium Health Resources, this change will be incorporated in the contract. All other terms of the contract will remain the same.