Nonparticipating Provider Data Update Form

Please enter the updated information and click “Review and Submit” at the bottom of the page to submit the eForm.

Effective Date*

Group/Entity Name*

Group/Entity TIN*

Group/Entity NPI*

Select all updates that apply*

Add a New Provider to a Practice/Group
Add a Practice Location to a Current Group
Billing Address Update
Mailing/Correspondence Address Update
Name Change
Terminate/Close a Practice
Update Practice Location for an Existing Provider

Add a new provider to a practice/group

Please complete the following information to add a new provider to a practice/group that is currently contracted with Neighborhood Health Plan of Rhode Island. If you require a new contract with Neighborhood, please go to the Join our Network web page.

Provider NPI*

Provider Name*

Primary Specialty*

Secondary Specialty

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Add a Practice Location to a Current Group

Please complete the following information to add a new practice/group location to an existing entity with Neighborhood Health Plan of Rhode Island.

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Practice Fax*

Provider(s) Impacted by Update

Provider’s Full name*

Provider NPI*

Provider’s Full name

Provider NPI

Provider’s Full name

Provider NPI

If additional providers are impacted, please attach a list (Excel or Word) that includes the provider’s full name and NPI

Drop files here or

Accepted file types: xls, xlsx, doc, docx, Max. file size: 200 MB.

Billing Address Update

Please complete the following information to remove existing billing address information for your practice/group and replace with new billing information. If you need to update your mailing/correspondence address and/or practice location, please complete those sections on this form, as well.

Previous Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

New Billing Address*

Street Address Address Line 2 City State ZIP Code

New Phone*

New Fax*

Upload supporting documents (e.g., W9)

Drop files here or

Max. file size: 200 MB.

Mailing/Correspondence Address Update

Please complete the following information to remove existing mailing/correspondence address information for your practice/group and replace with new mailing/correspondence information. If you need to update your billing address and/or practice location, please those sections of this form, as well.

Previous Mailing/Correspondence Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

New Mailing/Correspondence Address*

Street Address Address Line 2 City State ZIP Code

New Phone*

New Fax*

Name Change

Please complete the following information to change the name of a provider.

Provider NPI*

Former Provider Name*

New Provider Name*

Primary Specialty*

Please upload supporting documentation of name change (e.g., new license, marriage/divorce certificate, etc.)*

Drop files here or

Max. file size: 200 MB.

Terminate/Close a Practice

Please complete the following information to close a practice/group.

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Practice Fax

Provider(s) Impacted by Update

Provider’s Full name*

Provider NPI*

Provider’s Full name

Provider NPI

Provider’s Full name

Provider NPI

If additional providers are impacted, please attach a list (Excel or Word) that includes the provider’s full name and NPI

Drop files here or

Accepted file types: xls, xlsx, doc, docx, Max. file size: 200 MB.

Update Practice Location for an Existing Provider

Please complete the following information to add/remove a practice location for a provider. This form should be used when a provider is moving to a new location within the same group.

Provider Name*

Provider NPI*

Primary Specialty*

Secondary Specialty

Select Action*

Select Action *

Add Location
Remove Location

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Add additional location 1

Add additional location

Select Action*

Select Action *

Add Location
Remove Location

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Add additional location 2

Add additional location

Select Action*

Select Action *

Add Location
Remove Location

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Add additional location 3

Add additional location

Select Action*

Select Action *

Add Location
Remove Location

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Contact Information

Office Contact Name*

Office Contact Email Address*

Details for the person submitting the form

Name*

Title*

Phone Number*

Email*

Date

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