Skip to main content
Skip to home page
Javascript must be enabled for the correct page display
812-450-5000
Schedule Appointments
Immediate Care
MyChart
Find a Doctor
Services
Locations
Pay My Bill
RX Refills
Giving
Classes + Events
Careers
For You
Deaconess Mobile App
Patients & Visitors
Healthcare Professionals
Donors and Volunteers
Employees
Business Solutions
Job Seekers
Students
Community
Your Health
Contact Information
For You App
Pay My Bill
My Chart
Giving
Classes + Events
Careers
Contact
Search
Find a Doctor
Locations
Services
Your Health
For You
Schedule Now
Deaconess Health Plans
/
For Providers
/
Provider Update Form (PUF)
Provider Update Form
** IMPORTANT **
You must submit a W9 and sample CMS 1500 form for each location change or addition.
Submitter Information
Person Completing Form:
Phone:
Email:
Provider Identification
Provider's First Name:
MI:
Last Name:
Degree:
Provider's Individual NPI:
Provider Name Change
Previous Name:
New Name:
Reason for Name Change:
Items required for name change: License, DEA, CSR, Certificate of Insurance (COI), Collaborative Practice Agreement (CPA), 1500 claim form (blinded/voided), Legal Document supporting name change (marriage license, court document, etc.) driver’s license
Terminating a Provider
Termination Date:
TIN(s):
Reason for termination:
Adding a Practice Location
Items required to add location Certificate of Insurance (new TINs), W9, 1500 claim form (blinded/voided), Collaborative Practice Agreement (CPA) if applicable
Practice Name:
Practice Group NPI:
Tax ID:
Street:
City:
State:
Select State
IL
IN
KY
ZIP:
County:
Select County
Crawford
Daviess
Dubois
Gibson
Henderson
Hopkins
Jefferson
Knox
Lawrence
Marion
Martin
Orange
Perry
Pike
Posey
Richland
Saline
Spencer
Sullivan
Union
Vanderburgh
Wabash
Warrick
Wayne
Webster
White
Phone:
Fax:
Office Manager/Contact:
Email:
Is this the primary location for provider?:
Yes
No
Effective Date:
List location in provider directory? (Only locations where patients are routinely seen should be listed in directory.):
Yes
No
Specialty Practiced at this Location:
If adding a practice location, you must complete the "Add A Pay To/Remit To Location".
Add a Pay to/Remit to Location
Pay to/Remit to Name:
Street:
City:
State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP:
Phone:
FAX:
Billing Manager/Contact:
Email:
Effective Date:
Eliminate Practice Location
Practice Name:
Practice Group NPI:
Street:
City:
State:
Select State
Illinois
Indiana
Kentucky
ZIP:
TIN:
Effective Date:
Change Practice Location
Old Practice Name:
New Practice Name:
Old Practice Tax ID:
New Practice Tax ID:
Old Practice Group NPI:
New Practice Group NPI:
Old Practice Street:
New Practice Street:
Old Practice City:
New Practice City:
Old Practice State:
Select State
Illinois
Indiana
Kentucky
New Practice State:
Select State
Illinois
Indiana
Kentucky
Old Practice ZIP:
New Practice ZIP:
Old Practice Manager:
New Practice Manager:
Old Practice Email:
New Practice Email:
Old Practice Phone:
New Practice Phone:
Old Practice Fax Number:
New Practice Fax Number:
Effective Date:
Change Pay to/Remit to Location
Old Pay/Remit Name:
New Pay/Remit Name:
Old Pay/Remit Tax ID:
New Pay/Remit Tax ID:
Old Pay/Remit NPI:
New Pay/Remit NPI:
Old Pay/Remit Street:
New Pay/Remit Street:
Old Pay/Remit City:
New Pay/Remit City:
Old Pay/Remit State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
New Pay/Remit State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Old Pay/Remit ZIP:
New Pay/Remit ZIP:
Old Billing Manager/Contact:
New Billing Manager/Contact:
Old Pay/Remit Email:
New Pay/Remit Email:
Old Pay/Remit Phone:
New Pay/Remit Phone:
Effective Date:
Additional Information
Comments:
Attachment:
ATTACH FILE
A single document can be attached to this request. You can combine all of the documents required into a single pdf file or create a zip file. If you do not wish to attach, the documents can be faxed to 812-450-2030.
Top
/Deaconess Health Plans/For Providers/Provider Update Form (PUF)
Back to top