MINNESOTA UNIFORM PRACTITIONER CHANGE FORM – Revised March ...
MINNESOTA UNIFORM PRACTITIONER CHANGE FORM – Revised April 2009
Add – Remove – Change Demographic Data for Credentialed Practitioners and Specialists Not Subject to Credentialing: ER Physician,
Pathologist, Radiologist, Anesthesiologist, CRNA, Neonatologist, Dietitian, Therapists (PT;OT; SLP), Audiologist – check with entity if unsure
|Demographic Verification and Authorization |
|Completed and authorized on behalf of the practitioner by: |
|Name: | |
|Clinic Name: | |
|Phone #: | |Fax #: | |E-Mail: | |
|Signature: | |Title: | |Date: | |
|Practitioner Demographic Information for this Request |
| | | | | | | | |
|Last: | |First: | |MI: | |SSN: | |
| | | | | |DOB: | |
|Title: |MD DO DDS | |Other | | | |
| | | |Title: | | | |
| |DC DPM Ph.D | | | | | |
| | | | | | | |
| | | | | Female | Male |
|DEA: | |State: | |Type I NPI: | |
|ADD/REMOVE Practitioner |
| Clinic Hospital Clinic/Hospital Name: |Phone: |
|Address: |City/State: |Zip: |
|Tax ID: |Type 2 NPI for this site: |Directory Suppress? YES NO |
|Effective Date: |Practicing Specialty at this Site: |Primary Site? YES NO |
| | | |
| ADD | REMOVE |Remove ALL sites for this TIN? YES NO |Remove Reason: |
|List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form. |
|ADD/REMOVE Practitioner |
| Clinic Hospital Clinic/Hospital Name: |Phone: |
|Address: |City/State: |Zip: |
|Tax ID: |Type 2 NPI for this site: |Directory Suppress? YES NO |
|Effective Date: |Practicing Specialty at this Site: |Primary Site? YES NO |
| | | |
| ADD | REMOVE |Remove ALL sites for this TIN? YES NO |Remove Reason: |
|List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form. |
|ADD/REMOVE Practitioner |
| Clinic Hospital Clinic/Hospital Name: |Phone: |
|Address: |City/State: |Zip: |
|Tax ID: |Type 2 NPI for this site: |Directory Suppress? YES NO |
|Effective Date: |Practicing Specialty at this Site: |Primary Site? YES NO |
| | | |
| ADD | REMOVE |Remove ALL sites for this TIN? YES NO |Remove Reason: |
|List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form. |
|CHANGE Practitioner Demographic Data |
|Old: | |New: | |
|Last Name: | |Last Name: | |
|First Name: | |MI: | |First Name: | |MI: | |
|Specialty: | |Specialty: | |
|License #: | |License #: | |
|DEA #: |(Include State) |DEA #: |(Include State) |
| | | | |
|Type I NPI #: | | Type I NPI #: |(Please attach copy of NEW DEA Certificate to this form) |
| | | | |
| | | | |
| | |
|Effective Date of Change: | |
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