Free ForwardHealth Provider Change of Address or Status, F01181 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1181 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

PROVIDER CHANGE OF ADDRESS OR STATUS
Instructions: Type or print clearly. Before completing this form, read the Provider Change of Address or Status Completion Instructions, F-1181A. Submit the completed form to ForwardHealth, Provider Enrollment, 6406 Bridge Road, Madison, WI 53784-0006. Providers may contact Provider Services at (800) 947-9627 for more information. SECTION I -- IDENTIFYING INFORMATION 1. Name -- Provider (Required) 2. Provider ID (Required)

3. Taxonomy Code (Required for Health Care Providers)

4. ZIP+4 Code (Required)

5. Updates on this form are applicable to the following programs. (Required) Wisconsin Medicaid Wisconsin Chronic Disease Program Wisconsin Well Woman Program SECTION II -- PRACTICE LOCATION INFORMATION 6. Name -- Contact Person

7. Telephone Number -- Contact Person

8. Telephone Number -- For Member Use

9. Address Line 1

10. Address Line 2

11. City

12. State

13. ZIP+4 Code

14. County

SECTION III -- PROVIDER FINANCIAL INFORMATION Taxpayer Information 15. Taxpayer Identification Number (TIN) 16. Name -- Taxpayer

17. TIN Type EIN SSN

18. TIN Effective Date

19. TIN End Date

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PROVIDER CHANGE OF ADDRESS OR STATUS F-1181 (10/08)

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SECTION III -- PROVIDER FINANCIAL INFORMATION (Continued) Checks and Remittance Advice Address 20. Address Line 1 21. Address Line 2

22. City

23. State

24. ZIP+4 Code

25. Name -- Financial Contact Person

26. Telephone Number -- Contact Person

SECTION IV -- IRS FORM 1099 MAILING ADDRESS IMPORTANT: Only one 1099 will be sent per TIN. If the provider completing this form is not responsible for receiving the 1099, the provider should not complete this section. 27. Address Line 1 28. Address Line 2

29. City

30. State

31. ZIP+4 Code

SECTION V -- MAILING INFORMATION 32. Name -- Mail To 33. Name -- Attention Line

34. Address Line 1

35. Address Line 2

36. City

37. State

38. ZIP+4 Code

SECTION VI -- PRIOR AUTHORIZATION INFORMATION 39. Name -- Provider 40. Name -- Attention Line

41. Address Line 1

42. Address Line 2

43. City

44. State

45. ZIP+4 Code

46. Fax Number

47. Telephone Number -- Contact Person

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PROVIDER CHANGE OF ADDRESS OR STATUS F-1181 (10/08)

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SECTION VII -- SUPERVISING PROVIDER INFORMATION (For Non-billing Providers Only) 48. Name -- Supervisor 49. Telephone Number -- Supervisor

50. Address Line 1

51. Address Line 2

52. City

53. State

54. ZIP+4 Code

55. Effective Date of Supervision

SECTION VIII -- GENERAL INFORMATION 56. Language(s) English Russian Spanish Hmong Other 57b. DEA Number(s)

57a. Drug Enforcement Agency (DEA) Number(s)

57c. DEA Number(s)

57d. DEA Number(s)

58. Is the provider Medicare Part A enrolled? 59. List Secondary NPIs for Medicare Part A.

Yes

No

Effective Date

60. Is the provider Medicare Part B enrolled? 61. List Secondary NPIs for Medicare Part B.

Yes

No

Effective Date

62. Is the provider DMERC enrolled? 63. List Secondary NPIs for DMERC.

Yes

No

Effective Date

Note: If an organization has identified subparts for the purpose of submitting claims to Medicare and the NPIs will only appear on automatic crossover claims to ForwardHealth, the NPIs submitted to Medicare on claims are considered to be secondary NPIs. SECTION IX -- AUTHORIZED SIGNATURE INFORMATION 64. SIGNATURE -- Provider (Required) 65. Date Signed (Required)

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