Change of Address Request

DEMOGRAPHIC CHANGE REQUEST FOR PHYSICIAN & DENTIST MUST COMPLETE

PHYSICIANS- FIRST NAME: MI: LAST NAME:

Medical License #: NPI: Taxonomy:

LAST KNOWN ADDRESS: Address: City: County: Zip Code:

NEW Office Practice INFORMATION: HOSPITAL AFFILIATIONS (if there are any changes)

(1) (2)

Practice Mode: Solo Group Hospitalist Other Effective date: CMS Specialty Program: RPICC CPT ES

Name of Group or Employer:

A. Primary Practice Address:

City: County: Zip Code:

Telephone: ( ) Fax ( ) Email: FED (Federal Employer ID#) B. ADD or REMOVE Other Office Locations 1. Address: City: County: Zip Code:

Telephone: ( ) Fax ( ) 2. Address: City: County: Zip Code:

Telephone ( ) Fax ( )

C. Billing Information (if different from primary office location) Billing Address: City: County: Zip Code:

Telephone ( ) Fax ( )

 Provider Relations Liaison (PRL)

Created on 10/05; 1/05; 9/06; 3/09; 6/11; 8/11; 3/12; 2/13 Mailing Address: Children’s Medical Services 4052 Bald Cypress Way, BIN A06 Tallahassee, FL 32339 (Print Name) Completed by: Office Manager Physician  Other Date: Fax completed form to CMS Central Office: Attn: Provider Management Fax: 850-487-1279

Created on 10/05; 1/05; 9/06; 3/09; 6/11; 8/11; 3/12; 2/13 Mailing Address: Children’s Medical Services 4052 Bald Cypress Way, BIN A06 Tallahassee, FL 32339