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Get Caresource 2016-2024

CareSource Provider/Group Hierarchy Change Request Form Date PR Rep Adding a Provider Deleting a Provider Changing Demographics Ex. Return to Providermaintenance caresource. com OR Fax to 937 396-3076 Revision Date 05/19/2016 CS-0208c Age Restrictions 18 yrs older Race/ Ethnicity Gender. Practice location change specialty change NPI/Phone/Fax Change Capacity Restrictions Details regarding any of the above changes can be placed in NOTES section on the last page Group IRS Name Group DBA Group TIN Group NPI Group Medicare Medicaid-OH Just4Me-WV Product MyCare-OH Just4Me-OH MedicareAdv-OH CTP-OH Just4Me-KY Just4Me-IN Office Contact Contact Name Contact Phone Contact Email Please indicate if you are FQHC RHC QFPP CMHC Contract Signatory Name Individual who is legally authorized to sign documents Signatory Title Signatory Email Address Remit Name Remit Mailing Same as above Contractual Updates Street City State Zip Provider Information Name Deg. ST County Phone Fax NPI John Doe SAMPLE MD 123 Main St Anywhere OH 45123 Greene 937-555-1212 1231231291 CAQH Medicare Specialty PCP Y/N If Y Capacity 1234567 FP Y Race/Ethnicity Asian Black or African American* Hispanic or Latino American Indian White Other Choose Not to Answer Notes Please insert rows if more lines are needed* Important Please include W-9 and ensure all CAQH applications are updated and accurate to ensure timely processing of providers. Practice location change specialty change NPI/Phone/Fax Change Capacity Restrictions Details regarding any of the above changes can be placed in NOTES section on the last page Group IRS Name Group DBA Group TIN Group NPI Group Medicare Medicaid-OH Just4Me-WV Product MyCare-OH Just4Me-OH MedicareAdv-OH CTP-OH Just4Me-KY Just4Me-IN Office Contact Contact Name Contact Phone Contact Email Please indicate if you are FQHC RHC QFPP CMHC Contract Signatory Name Individual who is legally authorized to sign documents Signatory Title Signatory Email Address Remit Name Remit Mailing Same as above Contractual Updates Street City State Zip Provider Information Name Deg. ST County Phone Fax NPI John Doe SAMPLE MD 123 Main St Anywhere OH 45123 Greene 937-555-1212 1231231291 CAQH Medicare Specialty PCP Y/N If Y Capacity 1234567 FP Y Race/Ethnicity Asian Black or African American* Hispanic or Latino American Indian White Other Choose Not to Answer Notes Please insert rows if more lines are needed* Important Please include W-9 and ensure all CAQH applications are updated and accurate to ensure timely processing of providers. .

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