TIN Updates

TIN Updates

To download the forms needed, click the links below.
Email *
example@example.com
Provider's Name *

First Name Last Name
Provider NPI # *
Type of Change *

Switching TINs ***As of 8/10/2020 there is a $350 charge to switch or add a TIN. Payment must be received before the TIN is processed. Add an additional TIN ***As of 8/10/2020 there is a $350 charge to switch or add a TIN. Payment must be received before the TIN is processed. Term an Old TIN ***No charge
Start Date of Change *

Month Day Year
Date
End Date of Old TIN

Month Day Year
Date
New Legal Business Name
New Tax ID
New Group NPI
Old Tax ID
New Practice Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Practice Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Fax Number *

Area Code Phone Number
New Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Billing Phone

Area Code Phone Number
Billing Fax Number

Area Code Phone Number
Office Hours *
Age Limits *
Gender Limits *
Primary Hospital
If None, type "None"
Upload New W9

Browse Files
http://bit.ly/W9-TIOPA Cancel of
Upload New Provider Relations Packet

Browse Files
One is Required for Each TIN - We cannot use on file items. Cancel of
Upload Tiopa Addendum

Browse Files

Cancel of
Important Document Copies: SSN, Driver's License, COI, (if applicable) CLIA, (if applicable) Radiology Cert

Browse Files
Please upload a copy of each file listed to the left. Cancel of
Allied Health Professional Collaborative Agreement Protocols

Browse Files
http://bit.ly/TIOPAProtocols-PA http://bit.ly/TIOPAProtocols-NP Cancel of
Download forms below:
W9

Provider Relations Packet

Tiopa Addendum

Physician's Assistant Protocols

Nurse Practitioner Protocols
Should be Empty:

TIN Updates

Download forms below: