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.
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 #
Office Hours
Remove Main Contact:
Street Address County
City State Zip+4
Phone # Fax #
Office Hours
Add NEW Office (Site) Location:
Street Address County
City State Zip+4
Phone # Fax #
Office Hours
PREVIOUS Office (Site) Location :
Street Address County
City State Zip+4
Phone # Fax #
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Trillium - Provider Change FormRevised 12.10.15
Remove Office (Site) Location :
Street Address County
City State Zip+4
Phone # Fax #
Office Hours
New Billing Location: (Attach copy of your up-to-date W-9)
Street Address County
City State Zip+4
Phone # Fax #
Office Hours
PREVIOUS Billing Location:
Street Address County
City State Zip+4
Phone # Fax #
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
[email protected] Attn: Ty Martin
112 Health Drive
Greenville, NC 27834
SUBMIT COMPLETED FORM BY EMAIL, FAX OR USPS TO:
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.
