AVESIS THIRD PARTY ADMINISTRATORS, INC
|Line of Business: Dental Hearing Vision |
|Please Choose from the following changes: |
|Address Phone/Fax/Hours Billing Address Change TIN (W9 Required) |
|Add Location (W9 Required) Add Provider (W9 Required) Practice Name (W9 Required) Other |
|Original Practice Name (required): |
|Original Tax ID (required): |
|State: |
|Contact Person’s name, phone, and/or email: |
|Address Change |Effective Date of Change: |
|Old address: |
|New Address: |
|Providers at new location: |
|Does the location have handicap access? Yes No |Accepts Dev. Disabilities patients Yes No |
|Phone/Fax/Hours |Effective Date of Change: |
|New Phone Number: |New Fax Number: |
|Office Hours: |Mon. |
|Old address: |
|New Billing Address: |
|Tax ID Change (W9 Required) |Effective Date of Change: |
|*If change effects more than one location please identify location(s) and provider(s): |
|Add Location (W9 Required) |Effective Date of Change: |Tin: |
|Address: |
|New Phone Number: |New Fax Number: |Email: |
|Providers at Location: |
|Office Hours: |Mon. |
|Practice Name (W9 Required) |Effective Date of Change: |
|New Practice Name: |
|*If change effects more than one location please identify location(s) and provider(s): |
|Add Provider (W9 Required) |Effective Date of Change: |Provider Name: |
|List address(es) that provider will be practicing at: |
|If you are adding a provider that is NOT in the Avesis Network, please contact your Provider Relations Representative. The provider MUST go through the |
|credentialing process. |
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P: 800-952-6674
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