Edit, Download, and Sign the Molina Healthcare Provider Information Change Form
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How do I fill this out?
To fill out this form, begin by entering your current practice information. Ensure that every required field is completed accurately. Double-check all details before submitting to avoid processing delays.
How to fill out the Molina Healthcare Provider Information Change Form?
1
Gather all necessary current practice information.
2
Complete the required fields with accurate details.
3
Review the changes you are requesting.
4
Sign where indicated to authorize the changes.
5
Submit the form along with any supporting documents.
Who needs the Molina Healthcare Provider Information Change Form?
1
Healthcare providers updating their practice information.
2
Organizations that specialize in provider directories.
3
Administrative staff needing to maintain accurate records.
4
Providers entering new affiliations or specialties.
5
Offices undergoing a change in ownership or location.
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Open the PDF in the PrintFriendly editor.
2
Select the text you want to modify.
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Type in your new information directly.
4
Review your changes for accuracy.
5
Download the edited PDF for your records.
What are the instructions for submitting this form?
To submit this form, fax it to the MHT PIM Department at (877) 319-6851 or email it to MHT.PIM@molinahealthcare.com. Ensure that all required documentation is attached, particularly if your changes affect your W-9 form. For physical submissions, mail the completed forms to the address indicated on the form.
What are the important dates for this form in 2024 and 2025?
Important dates for this form are set for annual updates and include the end of each quarter. Providers should aim to submit changes promptly after any adjustments to maintain compliance. Check for any additional notices or requirements issued by Molina Healthcare.
What is the purpose of this form?
The Provider Information Change Form is designed to allow healthcare providers to update their essential practice details effectively. Keeping current practice information is vital for accurate directory listings and compliance with Molina Healthcare's operational standards. This form facilitates seamless updates to ensure providers are accurately represented.
Tell me about this form and its components and fields line-by-line.
- 1. Type of Provider: Indicates the category of healthcare provider.
- 2. Type 1 (Individual) NPI: The National Provider Identifier for individual providers.
- 3. Provider Name: Full legal name of the healthcare provider.
- 4. Tax ID: Tax identification number for the practice.
- 5. Primary Specialty: Main area of specialty for the provider.
What happens if I fail to submit this form?
Failing to submit this form can result in outdated practice information in directories, impacting provider visibility and compliance with healthcare regulations. Malfunctions in your billing processes might occur if Tax ID changes are not reported.
- Outdated Information: Providers may not be recognized properly by patients or other providers.
- Non-Compliance: This can lead to penalties or loss of practice privileges.
- Billing Issues: Failure to update Tax ID can cause billing complications.
How do I know when to use this form?
- 1. Change of Address: Submit when moving to a new practice location.
- 2. Update Phone Number: To ensure patients can reach you correctly.
- 3. Add New Specialties: When expanding the services your practice offers.
Frequently Asked Questions
How do I access the Provider Information Change Form?
You can download the form directly from our website.
Can I edit this PDF before submission?
Yes, use PrintFriendly to edit the PDF as needed.
What should I do if I have trouble filling it out?
Contact our support team for assistance with the form.
Is there a specific submission deadline?
Changes must be submitted within 30 days of completion.
Do I need to submit a W-9 form?
Yes, if your changes affect your Tax ID.
How do I ensure my changes are processed quickly?
Fill out all required fields accurately.
Can I submit this form by email?
Yes, send it to MHT.PIM@molinahealthcare.com.
What happens after I submit the form?
You will receive confirmation regarding your changes.
Is there a contact for questions about the form?
You can reach the PIM Department at (877) 319-6851.
Can I track the status of my submission?
Currently, tracking submissions is not available.
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