Organization Maintenance Change Request Form

Rev. 04.16.2016.1

Instructions

1. Complete the Organization Information section.

2. (Optional) To change your organization’s NPI or tax ID, complete the Change Organization NPI or Tax ID

section.

› Availity allows only one NPI for each organization. To associate additional providers to your organization

for express entry on transactions, go to My Account | Express Entry in the Availity Web Portal.

› If your tax ID has changed but your organization has not changed ownership, enter your new tax ID in the

Availity Web Portal instead of completing this form. Go to Account Administration | Maintain

Organization, and enter the new tax ID in the Tax ID field on the Organization Information page.

3. (Optional) To change your organization type, complete the Change Organization Type section.

Important: If your organization has contracts with payers in more than one state (geographic location),

contact Availity Client Services at 1.800.282.4548 to update your organization’s account.

4. Have the form signed by your organization’s Administrator and witnessed by a person not named on this form.

5. Return the completed, signed form to Availity:

Fax Mail

904.470.2187 Attn: Availity Security

Availity, L.L.C. Registration Department PO Box 550857 Jacksonville, FL 32255-0857

Organization Information (all fields required as currently on record with Availity)

Organization Name: Customer ID:

City: State:

Administrator Last Name:

Organization Maintenance Change Request Form

Rev. 04.16.2016.1

Change Organization NPI or Tax ID

Note: To change an existing identifier, complete two rows—one to delete the original identifier, and one to add the new identifier.

Add Delete

Identifier Type (select one)

Enter the NPI or Tax ID

1

2

3

4

5

6

7

8

Change Organization Type

To change your organization type with Availity, select the check box next to the new organization type below. Be careful when requesting this change. Not all organization types receive access to the same features in Availity

Ambulatory Surgical Center Hospital Non-Physician Provider

Billing Service IPA Pharmacy

Durable Medical Equipment Laboratory Physician Practice

Home Healthcare Long-Term Care Facility Urgent Care

Hospice Multi-Physician Practice

Signatures

Administrator

I, , the undersigned Administrator, do hereby attest to the accuracy and completeness of the information provided by the organization in this document and attest that I have the authority to, and hereby do, make these changes on behalf of the organization.

Signature:

Date:

Witness

Name:

(print or type)

Signature:

Date:

(must match Administrator signature date)