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Telehealth Requirement on Practitioner Demographic Changes Form

Audience: Participating Providers and Other Health Care Professionals

We would like to make you aware of an update regarding the telehealth question on the Practitioner Demographic Changes form. For demographic changes submitted with information in the address field(s), the “Is this address used for Telehealth services?” question is required for each address line being completed on the form.

Starting April 1, 2021, any Practitioner Demographic Changes form received without the telehealth question completed on the applicable address line(s) will be rejected.

Visit our website to complete and submit the most current version of our Practitioner Demographic Changes form for the following changes. Out-of-date forms will be rejected and should be discarded. ­

  • Practice and/or provider name ­

  • Phone number, fax number, and/or address ­

  • Office hours ­

  • National Provider Identifier (NPI) ­

  • Medical group affiliation ­

  • “Accepting new patients” status ­

  • Any other data changes that have occurred within your practice, displayed on the directory or not (including tax ID updates)

When you submit the form online through our provider portal, we don’t require a provider signature on the form because of your secure sign-on.

Please share this information with anyone in your practice or facility who submits demographic changes. Thank you for the quality of care and service that you provide to our valued members.

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