Provider/Group Change Form

PLEASE NOTE:

  • Billing address changes require an updated W-9 form.
  • Changes to Tax ID numbers require 45 days written notice from the provider. MedStar Family Choice will confirm receipt of the Tax ID notice in writing within 30 days after acceptance of the Tax ID change.
  • Provider terminations are not considered changes and a 90-day written notice is required as per participation agreements.
  • Tax ID Changes require new contractual agreements and cannot be processed without an executed agreement.

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