External Demographic Form

External Demographic Form

This form is for providers to notify us of any new information or changes to their practice structure.

This form is not used to add a practitioner to your practice. To add a practitioner(s) to your practice, email KPWA.provider-services@kp.org.

TERM YOUR PROVIDER CONTRACT: Email prnotification@kp.org.

Requestor Name*

Requestor Email*

Requestor Phone*

Phone

Contracting Relationship*

CONTRACTED - If your Tax ID is Contracted directly with Kaiser Permanente of Washington (Kaiser Foundation Health Plan of Washington (KFHPWA) or Kaiser Foundation Health Plan of Washington Options, Inc.

NON-CONTRACTED - If your Tax ID contract is held by WholeHealth (Tivity) or First Choice/First Health, that is considered not contracted directly with Kaiser Permanente.

Are you an Alternative Medicine Provider?*

Massage Therapist, Chiropractor, Acupuncturist or Naturopath

Yes

ALERT: MASSAGE THERAPISTS, ACUPUNCTURISTS, CHIROPRACTORS, NATUROPATHS

STOP - DO NOT USE COMPLETE THIS FORM, CONTACT TIVITY/WHOLEHEALTH

Contact Tivity for any demographic changes at Practitioner.updates@tivityhealth.com. Kaiser Permanente can only make changes received from Tivity since they hold your contract. Thank you.

Are you a Mental Health provider?*

Yes

Mental Health Providers: Are you changing your Tax ID or Tax ID Name?

Yes

ALERT

Providers delegated to Magellan must ALSO update Magellan's portal with all changes.

PLEASE NOTE: Providers delegated to Magellan

PLEASE DO NOT COMPLETE THIS FORM UNLESS IT'S A TAX ID OR TAX ID NAME CHANGE. We are not able to make other demographic changes unless they come from Magellan.

Magellan providers must update their demographic data on Magellan’s website.

Make the changes using the online Provider Data Change Form.

Here's how:

To review and update your practice data:

1. Go to www.MagellanHealth.com/provider.

2. Securely sign in with your username and password. (Click Forgot Password? or Forgot Username? if you need to obtain your website sign-in.)

3. Click Display/Edit Practice Information from the left-hand menu.

4. The first tab that displays is the Provider Data Change Form.

Need Assistance? Refer to the Help text that accompanies the online form, listen to a recorded webinar, or check out our Provider Data Change Form demo.

Or email washingtonprovider@magellanhealth.com for help.

You can learn more about Kaiser Permanente's relationship with Magellan Health here: https://wa-provider.kaiserpermanente.org/static/pdf/provider/communications/letters/20200428-magellan.pdf

Existing Tax ID*

Please enter numbers only, no dashes. Must be 9 digits long

Tax ID Type*

EIN

SSN

Contract Name on W9*

This should be your IRS registered business Tax ID Name

Effective Date*

Helpful Notes

HR133

HR133 – Legislation - Per the federal Consolidated Appropriations Act, any of the items to the right must be loaded into our systems within 2 business days. Please be aware that this information will not be reviewed and will be loaded exactly as submitted. This is an abbreviated form specifically for ensuring compliance to the 2-business day turnaround required by HR133.

CARE SITE CHANGES

Are you adding a New Care Site?*

Do not use if you are changing an address for a current care site. Please use "Are you Updating Existing Care Site Information" instead.

Yes

Are you Closing a Care Site?*

If you are just changing a care site address (moving to a new location), please move to the next questions

Yes

Care Site Closure Reason*

Are you Updating Existing Care Site Information?*

Yes

Main Care Site Street Address*

Select or enter value

Main Care Site City*

Select or enter value

Main Care Site State*

Select or enter value

Main Care Site Zip*

Select or enter value

Main Care Site Name*

Select or enter value

Main Care Site County*

Select or enter value

Care Site Services*

Main Care Site NPI #*

Are you Changing a Care Site Name?*

Yes

Updated: Main Care Site Name*

Are you Updating a Care Site Address?*

Yes

King/Non King County Rate Change*

Yes

Updated: Main Care Site Street Address*

Updated: Main Care Site City*

Updated: Main Care Site State*

Select or enter value

Updated: Main Care Site Zip*

Updated: Main Care Site County*

Are you Changing a Care Site Phone/Fax #?*

Yes

Main Care Site Phone #*

Phone

Updated: Main Care Site Phone #

Phone

Main Care Site Fax #

Phone

Updated: Main Care Site Fax #

Phone

Please enter information for Practitioner practicing at New Care Site. If there are no practitioners being added, enter "N/A" in those fields

INDIVIDUAL PRACTITIONER NAME CHANGE

Are you Changing a Practitioner's Name?*

This is for an actual practitioner's personal name change. If you are changing a clinic name, please use the field above called "Are you updating a Care Site Name?

Yes

Required: * Attach copy of current license at bottom of form

Individual NPI #*

Practitioner First Name*

Practitioner Middle Name

Practitioner Last Name*

Updated: Practitioner First Name*

Updated: Practitioner Middle Name

Updated: Practitioner Last Name*

GENERAL ORGANIZATION MAILING ADDRESS

Used for general correspondence (referral letters)

Are you changing you General Org Mailing Address?*

Yes

Updated: Provider Street Address*

Updated: Provider City*

Updated: Provider State*

Updated: Provider Zip*

Updated: Provider County*

Updated: Provider Phone #*

Phone

Updated: Provider Fax #*

Phone

BILLING / PAY TO CHANGES

THESE CHANGES AFFECT CLAIMS PROCESSING. Effective date on the form will be used for updates. Claims billed after the effective date must be submitted with the updated information to process appropriately. If enrolled in electronic funds transfer, you must also notify Instamed of billing NPI and Tax ID changes by emailing: Support@Instamed.com or contact Instamed customer service toll-free at 1-877-833-6821

Are you Changing your Remit/Pay To Address or Billing/Pay To NPI #?*

Billing Address & NPI are submitted in Box 33 on the claim form (CMS 1500) and directly impact claims processing if our system does not match what is submitted.

Yes

Updated: Billing / Pay to Name*

Updated: Billing / Pay To Street Address*

Updated: Billing / Pay To City*

Updated: Billing / Pay to State*

Updated: Billing / Pay To Zip*

Updated: Billing / Pay To Phone #*

Phone

Updated: Billing / Pay To Fax #

Phone

Updated: Billing / Pay To NPI #*

Updated: Billing / Pay To Taxonomy Code*

TAX ID INFORMATION

If your Tax ID or Business Name is changing please be sure to attach a current W9.

Are you changing your Tax ID Name?*

Yes

Tax ID Name Change Reason*

Please provide the following documents for Acquisitions/Assignments:

Bill of Sale signed by both parties which includes the effective date of the change
Updated W9 with new Tax ID
Official letter with the details listed below signed by both parties

Changing from Individual to Group Org

Acquisition of Business & Contracts

Assignment of Business & Contracts

Term Contract & Join Another Org

Updating Org Name with IRS/1099

Other (Provide Details)

Tax ID Name Change Reason Other Details

Updated: Tax ID Name*

Please upload a current W9 at the bottom of the form.

Are you Changing your Tax ID?*

Yes

Tax ID Change Reason*

Please provide the following documents for Acquisitions/Assignments:

Bill of Sale signed by both parties which includes the effective date of the change
Updated W9 with new Tax ID
Official letter with the details listed below signed by both parties

Changing from Individual to Group Org

Acquisition of Business & Contracts

Assignment of Business & Contracts

Term Contract & Join Another Org

Other (Provide Details)

Tax ID Change Reason Other Details

Tax ID NEW*

Please upload a current W9 at the bottom of the form.

Updated: Tax ID Type*

EIN

SSN

Are you changing your Tax Reporting (1099) Address?*

You must upload your revised W9.

Yes

Updated: Tax ID Street Address*

Please upload a current W9 at the bottom of the form.

Updated: Tax ID City*

Updated: Tax ID State*

Updated: Tax ID Zip*

Updated: Tax ID County*

Updated: Tax ID Phone #*

Phone

Updated: Tax ID Fax #

Phone

CONTRACTING CONTACTS

Contract Contact Name*

Contract Mailing Address*

Must include street address, Suite (if any), city, state, and zip

Contract Manager Email*

Contract Contact Phone #*

Phone

Contract Signatory Name*

Contract Signatory Title*

Upload current W9 or Current Updated Medical License, if appropriate

If a W9 or Medical License is not available to you right now, send to KPWA.provider-Services@kp.org and we will add them to this form. If you have any changes to this form after submission, you can email this same email and we will send you an Update Request so you can change this form. You do not have to submit the form again.

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