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* Fees apply for adding TINs
*
Switching TINs
Add an additional TIN
Term an Old TIN
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
Do you have a secondary location?
*
Yes
No
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
*
0-120 (All Patients)
18+ (Adults Only)
0-18 (Children Only)
Gender Limits
*
Both- Men & Women
Men Only
Women Only
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:
NP Protocols
PA Protocols
TIOPA Addendum
Behavioral Health - Chiropractors
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