Change Healthcare Provider Complete Enrollment & Deactivation

Please select one of the following:*

I would like to add a new practice for my billing service.
I would like to add a provider(s) to an existing practice.

Billing Service Name*

Contact Name*

First Last

Contact Phone*

Contact Email*

Billing Service Tax #:*

Connect to:*

Client
Host

Please provide your Vision Username:*

Please provide your Vision Email Address:*

Group/Practice Name*

Address*

Street Address Address Line 2 City State ZIP Code

Group Tax ID*

Group NPI*

Provider Name*

Name Credentials

Provider Tax ID*

Provider NPI*

Services Requested:* (Select all that apply)*

Claims, ERA & Real Time (Provider Inquiry)
Professional Claims (1500 CMS)
Institutional Claims (UB04)
EFT

Multiple Practices?*

*If you select Yes for Multiple Practices, please complete a new form for each Practice (unique Tax ID).*

Yes
No

Multiple Databases?*

Yes
No

Do you wish to add another provider?*

Yes
No

2nd Provider Name*

Name Credentials

Provider Tax ID*

Provider NPI*

Do wish to add another provider?*

Yes
No

3rd Provider Name*

Name Credentials

Provider Tax ID*

Provider NPI*

Do you wish to add another provider?*

Yes
No

4th Provider Name*

Name Credentials

Provider Tax ID*

Provider NPI*

Do you want to add another provider?*

Yes
No

5th Provider Name*

Name Credentials

Provider Tax ID*

Provider NPI*

Change Healthcare Provider Complete Enrollment & Deactivation

Change Healthcare Provider Complete Enrollment & Deactivation

Enroll Practice or Provider

Deactivate Provider

Provider Complete - Deactivate a Provider

Electronic Patient Statements

Electronic Patient Statements

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