Provider Update Form

Provider Update Form

Please fill out the following form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Facility Name
NPI
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload the following requested files
State and federal license, certifications, and accreditations

Cancelof
Professional and general liability insurance

Cancelof
W-9 Form

Cancelof
Updates to any programs or policies within the last year

Cancelof
Staff Roster/ Updates to any staff within the past year (i.e. CEO, Case Managers and Billing contacts)

Cancelof
If you need assistance or cannot provide the above documents, please reach out to Vikki at (800) 828-3939 x 25111 or by email at vikki@beatiteap.com
Should be Empty:

Please upload the following requested files