Address Updates – NHPRI.org

Address Type*

Mailing/Correspondence Address Update
Billing Address Update
Practice Address Update

Effective Date*

Group/Entity NPI*

Group/Entity Name*

Group/Entity TIN*

Practice Name*

Practice NPI (if applicable)

Mailing/Correspondence Address Update

Former Mailing/Correspondence Address*

Street Address Address Line 2 City State ZIP Code

Previous Phone Number*

Mailing

Previous Fax Number*

Mailing

New Mailing/Correspondence Address*

Street Address Address Line 2 City State ZIP Code

New Phone Number*

Mailing

New Fax Number*

Mailing

Billing Address Update

Previous Billing Address*

Street Address Address Line 2 City State ZIP Code

Previous Phone Number*

Billing

Previous Fax Number*

Billing

New Billing Address*

Street Address Address Line 2 City State ZIP Code

New Phone Number*

Billing

New Fax Number*

Billing

Practice Address Update

Previous Practice Address*

Street Address Address Line 2 City State ZIP Code

Previous Phone Number*

Practice

Previous Fax Number*

Practice

Previous Practice Address*

Street Address Address Line 2 City State ZIP Code

New Phone Number*

Practice

New Fax Number*

Practice

Does this office meet ADA Accessibility requirements?*

Does this office meet ADA Accessibility requirements? *

Yes
No

Does this site offer the following:

Handicap Accessible Building*

Handicap Accessible Building *

Yes
No

Handicap Parking*

Handicap Parking *

Yes
No

Handicap Restroom*

Handicap Restroom *

Yes
No

Handicap Accessible Exam Room*

Handicap Accessible Exam Room *

Yes
No

Does this site offer other services or programs for the disabled?

Is this site accessible by public transportation?

Bus*

Bus *

Yes
No

Subway*

Subway *

Yes
No

Provider(s) Impacted by Practice Address Update

Providers' Full Name*

Provider's NPI*

Is this location the providers' primary correspondence address?*

Is this location the providers' primary correspondence address? *

Yes
No

If additional providers are impacted, please attach a list (Excel or Word) that includes the providers’ full names and NPIs.

Upload Documents

Accepted file types: docx, xlsx, csv, Max. file size: 50 MB.

Administrative Information

Office Contact Name*

Office Contact Email Address*

Upload Updated W9*

(Note: Please ensure that the W9 has been signed and dated within the last 6 months.)

Drop files here or

Max. file size: 50 MB.

Details for the Person Submitting the Form

Name*

Title*

Phone*

Practice Fax*

Email*

Additional Information

Date

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