Thrive - Provider Updates - FCH First Choice Health

First Choice Health.
Provider Update Form
Please note: This form is intended for providers who are already credentialed with FCH.
Contact Name (First Name)
Contact Phone
Contact E mail Address
example@example.com
Effective Date of Change

MonthDayYear
Date
Provider Name
Provider NPI
Taxonomy
Please indicate the information type(s) you will be changing:

Provider information (multiple elements)Address InformationCorporate Name (W9 form required, please upload below)Tax ID Number (W9 form required, please upload below)Personal NameIndividual NPI #Phone NumberFax Number
PROVIDER CHANGES
TYPE OF PROVIDER CHANGE

ADDREMOVE
Tax ID Number
Address

Street Address

Street Address Line 2

CityState

Zip Code + Four
Check Appropriate Type of Address

Physical Practice Address (not PO Box)BillingMailingCredentialing
Phone Number
Hospital Affiliation
Languages Spoken (other than english):
Address ADA Accessible

YesNoTelemedicine
Address ADA Accessible

Women's HealthOB DeliveriesTelemedicine
Capacity (maximum number of patients that practitioner manages):
ADDRESS CHANGES
TYPE OF ADDRESS CHANGE

ADDREMOVE
Tax ID Number
Phone Number
Address

Street Address

CityState

Zip Code
Check Appropriate Type of Address

Physical Practice Address (not PO Box)BillingMailingCredentialing
Hospital Affiliation
Languages Spoken (other than English):
Address ADA Accessible

YesNo
Gender Limitations

MaleFemaleNone
Gender Limitations

Women's HealthOB DeliveriesTelemedicine
Minimum Age
Maximum Age
Capacity (maximum number of patients that practitioner manages):
Changes in the selected section assume that no other changes are needed. For example, if the information provided below is the Old and New Tax ID Number, we will update only the Tax ID Number and no other changes to existing information will be made.
Corporate Name Change

Dont forget to upload W-9 form below
OLD
NEW
Tax ID Number Change

Dont forget to upload W-9 form below
OLD
NEW
Personal Name Change
OLD
NEW
Individual NPI Number Change
OLD
NEW
Phone Number Change

(At Practice Location)
OLD
NEW
Fax Number Change

(At Practice Location)
OLD
NEW
W-9 File Upload

Cancelof
SUBMISSION INSTRUCTIONS:
Please make sure that any needed attachments (including W-9 and other pertinent documentation as needed) have been uploaded in relevent sections. Upon submitting this form, a copy will be emailed to ppofilemaintenance@fchn.com including any attachment(s) that have been uploaded. A copy will also be emailed to you using the address listed at the top of the form as well as to info@thrivepractices.com.

Any changes sent to Provider Information team will take approximately 30 business days to implement.

First Choice Health | One Union Square | 600 University Street, Suite 1400 Seattle, WA 98101
Should be Empty:

First Choice Health.

Provider Update Form

PROVIDER CHANGES

ADDRESS CHANGES

Corporate Name Change

Tax ID Number Change

Personal Name Change

Individual NPI Number Change

Phone Number Change

Fax Number Change

SUBMISSION INSTRUCTIONS: