Thrive - Provider Updates

PREMERA
PROVIDER UPDATE FORM
GENERAL INFORMATION
Practice name*
Practice tax ID/EIN*
Organization NPI*
Credentialing email
example@example.com
Primary office email
example@example.com
Name of individual completing form*
Individual's phone number*
Individual's email*
example@example.com
UPDATE TYPE

Please check all that apply
Change Applies to Entire Practice/Group*

Change Practice NameChange of ownership, tax ID or organization NPI #Change payment/remit addressChange credentialing addressChange communications address
Change Applies to Specific Practice or Group Location(s)*

Make changes to an existing location addressAdd a new practice locationRemove a practice location
Change Applies to Individual Provider(s). (For more than 1 Practitioner, submit 1 form per practitioner)*

Add PractitionerUpdate an existing practitionerRemove Practitioner
OTHER... If the reason for the change is not listed above, please write in the reason for form submission here:
Effective date of change*

MonthDayYear
Date
CHANGE OF PRACTICE NAME
New name
Previous name
CHANGE OF OWNERSHIP/TAX ID
New tax ID
Previous tax ID
New NPI
Previous NPI
* Please Upload a copy of the IRS SS-4 confirmation letter with this form.

Cancelof
MAKE CHANGES TO AN EXISTING LOCATION ADDRESS

*Note: For more than 1 location, please submit this form again
Change applies to (check all that apply)

LocationCommunicationCredentialingPayment
NEW Address

Street Address (include suite/building #)

Street Address Line 2

CityState

Zip Code
Phone
Fax
PREVIOUS Address

Street Address (include suite/building #)

Street Address Line 2

CityState

Zip Code
Phone
Fax
ADD OR REMOVE PRACTICE LOCATION(S) FROM ENTIRE GROUP
# of Locations to ADD/REMOVE (if more than 4, please fill out a second form)

1234
1st Location - ADD/REMOVE?

AddRemove
1st Location - Clinic NAME or DBA & Address

Clinic NAME or DBA

Street Address (include suite/building #)

CityState / Province

Postal / Zip Code
1st Location - Phone
1st Location - Fax
2nd Location - ADD/REMOVE?

AddRemove
2nd Location - Clinic NAME or DBA & Address

Clinic NAME or DBA

Street Address (include suite/building #)

CityState / Province

Postal / Zip Code
2nd Location - Phone
2nd Location - Fax
3rd Location - ADD/REMOVE?

AddRemove
3rd Location - Clinic NAME or DBA & Address

Clinic NAME or DBA

Street Address (include suite/building #)

CityState / Province

Postal / Zip Code
3rd Location - Phone
3rd Location - Fax
4th Location - ADD/REMOVE?

AddRemove
4th Location - Clinic NAME or DBA & Address

Clinic NAME or DBA

Street Address (include suite/building #)

CityState / Province

Postal / Zip Code
4th Location - Phone
4th Location - Fax
Do you need to add practitioners to these locations?

YESNO
Indicate the number of practitioners to be added to above location(s), please indicate first how many will be added. (Note* - If more than 12 are needed, please fill in the 1st 12 here, and fill out an additional form for additional practitioners)
01 - NAME/NPI

Full NameNPI #
02 - NAME/NPI

Full NameNPI #
03 - NAME/NPI

Full NameNPI #
04 - NAME/NPI

Full NameNPI #
05 - NAME/NPI

Full NameNPI #
06 - NAME/NPI

Full NameNPI #
07 - NAME/NPI

Full NameNPI #
08 - NAME/NPI

Full NameNPI #
09 - NAME/NPI

Full NameNPI #
10 - NAME/NPI

Full NameNPI #
11 - NAME/NPI

Full NameNPI #
12 - NAME/NPI

Full NameNPI #
ADD/REMOVE/UPDATE PRACTITIONER INFORMATION
To credential a new provider, see premera.com/wa/provider/reference/join-our-network/
Provider name
Provider NPI
List specialty if applicable (not licensure)
Primary care (Y/N)
List in directory (Y/N)
Virtual health (Y/N)
Accepting new patients

YesNoEstablished only
Assigning Practitioner to Location(s)? Please indicate how many
If more than 5, please fill out additional of this form
add #1 - Practice address (include suite/building #)
add #2 - Practice address (include suite/building #)
add #3 - Practice address (include suite/building #)
add #4 - Practice address (include suite/building #)
add #5 - Practice address (include suite/building #)
Removing Practitioner from Location(s)? Please indicate how many
If more than 5, please fill out additional of this form
Remove Practitioner from Practice Location(s)

ALLCertain Locations
remove#1 - Practice address (include suite/building #)
remove#2 -Practice address (include suite/building #)
remove#3 - Practice address (include suite/building #)
remove#4 - Practice address (include suite/building #)
remove#5 - Practice address (include suite/building #)
Please review to ensure all information is correct PRIOR to submission.

Upon submitting, this form will be automatically emailed to Premera, Thrive Practices, and a copy sent to the email listed below in the "Individual's email" field.
Should be Empty:

PREMERA

PROVIDER UPDATE FORM

GENERAL INFORMATION

UPDATE TYPE

CHANGE OF PRACTICE NAME

CHANGE OF OWNERSHIP/TAX ID

MAKE CHANGES TO AN EXISTING LOCATION ADDRESS

ADD OR REMOVE PRACTICE LOCATION(S) FROM ENTIRE GROUP

ADD/REMOVE/UPDATE PRACTITIONER INFORMATION