Address Change

Required fields are marked with an asterisk (*)

Group/Facility Name *

Tax Id # * (numbers only/without dash)

Group NPI # * NPI must be 10 numbers

Effective Date *

Billing Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Billing Address Phone Number * (numbers only/without dashes)

Comments

Please attach a completed W-9 or Notice on company letterhead of this change *

Please attach any additional supporting documents

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone * (numbers only/without dashes)

Date Requested *

Group/Facility Name *

Group NPI # * NPI must be 10 numbers.

Tax ID # * (numbers only/without dash)

Practitioner Name

First Name * Enter N/A if uploading a list of practitioners.

Middle

Last Name * Enter N/A if uploading a list of practitioners.

Suffix

Degree * Enter N/A if uploading a list of practitioners.

Practitioner NPI # * NPI must be 10 numbers. Enter 9999999999 if not available.

Multiple Practitioners For multiple practitioners at the same location, please upload an Excel spreadsheet with names and NPI numbers for each practitioner.

Please attach any additional supporting documents

Old Location Address

Location Name * Enter N/A if not available.

Street Address *

Address Line 2

City *

State *

Zip Code *

New Location Address

Effective Date *

Primary Location

Location Name * Enter N/A if not available.

Street Address *

Address Line 2

City *

State *

Zip Code *

New Location Phone * (numbers only/without dashes)

Appointments Accepted *

Yes No

Accepting New Patients *

Yes No Existing

Languages Spoken at Location *

Minimum Age Restrictions *

Maximum Age Restrictions *

Gender Restrictions *

No Restrictions Female Only Male Only

New Location Hours

Please specify if Closed, Open 24 hours, or Enter hours in 15 minute increments, ex. 9:15 AM.

Sunday Open *

Sunday Close *

Monday Open *

Monday Close *

Tuesday Open *

Tuesday Close *

Wednesday Open *

Wednesday Close *

Thursday Open *

Thursday Close *

Friday Open *

Friday Close *

Saturday Open *

Saturday Close *

Comments

Physical Accessibility Survey

Part I. Parking

Is there adequate, marked accessible (handicap) parking (1 in 25 or 10% of total spaces) at clinic that service people with mobility disabilities? *

Yes No

Do you have at least 1 space that is van accessible in your parking lot? *

Yes No

Is there an access aisle next to each marked space? *

Yes No

Part II. Route

Does the location provide easy access to public transportation? *

Yes No

Is the route of travel to the building stable, firm and slip resistant and at least 36” wide? *

Yes No

Part III. Entry

If there are stairs at the main entrance, is there a ramp or lift or is there an alternative accessible entrance? *

Yes No

Is the entry door at least 34” wide? *

Yes No

Does the entry door have a push pad or easy assist system? *

Yes No

Are elevators located on an accessible route with care control buttons designated with both raised characters and Braille symbols that are no higher than 54 inches from the floor, with audible signals for the up and down direction or verbal enunciators and doors and cabs with the appropriate dimensions? *

Yes No

Part IV. Restrooms

Is your restroom large enough to accommodate a patient who uses an adult wheelchair or scooter? *

Yes No

Are the entry doors to the restrooms are at least 36″ wide, and easy to open? *

Yes No

Does the toilet door or stall have a minimum clear opening of 32″? *

Yes No

Is there at least one open space (at least 42") to the side of the toilet? *

Yes No

Are there grab bars behind and to the wall side of the toilet? *

Yes No

Is the top of the toilet seat 17-19" from the floor? *

Yes No

Are the soap and towel dispensers 48" or less from the floor? *

Yes No

Part V. Exam Room

Is at least one of your exam rooms via an accessible route (no less than 36″ wide) with an entry door at 32″ clear opening with a minimum a 30″ by 48″ clear approach next to an examination table for transfer from a wheelchair? *

Yes No

Part VI. Equipment

Does your practice have access to a wheelchair scale? *

Yes No

Does your practice have a height adjustable exam table? *

Yes No

Part VII. Accommodations

Are staff members trained to assist with transfers on/off of examination table? *

Yes No

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number * (numbers only/without dashes)

Date Requested *

Group/Facility Name *

Tax ID # * (numbers only/without dash)

Group NPI # * NPI must be 10 numbers long.

Practitioner Name

First Name * Enter N/A if uploading a list of practitioners.

Middle

Last Name * Enter N/A if uploading a list of practitioners.

Suffix Enter N/A if uploading a list of practitioners.

Degree * Enter N/A if uploading a list of practitioners.

Practitioner NPI # * NPI must be 10 numbers long. Enter 9999999999 if not available.

Multiple Practitioners Upload For multiple practitioners at the same location, please upload an Excel spreadsheet with names, degrees and NPI numbers for each practitioner.

Please attach any additional supporting documents

Additional Location Address

Effective Date *

Location Name * Enter N/A if not available.

Street Address *

Address Line 2

City *

State *

Zip Code *

Location Phone Number * (numbers only/without dashes)

Appointments Accepted *

Yes No

Accepting New Patients *

Yes No Existing

Languages Spoken at Location *

Minimum Age Restrictions *

Maximum Age Restrictions *

Gender Restrictions *

No Restrictions Female Only Male Only

Comments

Location Hours

Please specify if Closed, Open 24 hours, or Enter hours in 15 minute increments, ex. 9:15 AM.

Sunday Open *

Sunday Close *

Monday Open *

Monday Close *

Tuesday Open *

Tuesday Close *

Wednesday Open *

Wednesday Close *

Thursday Open *

Thursday Close *

Friday Open *

Friday Close *

Saturday Open *

Saturday Close *

Physical Accessibility Survey

Part I. Parking

Is there adequate, marked accessible (handicap) parking (1 in 25 or 10% of total spaces) at clinic that service people with mobility disabilities? *

Yes No

Do you have at least 1 space that is van accessible in your parking lot? *

Yes No

Is there an access aisle next to each marked space? *

Yes No

Part II. Route

Does the location provide easy access to public transportation? *

Yes No

Is the route of travel to the building stable, firm and slip resistant and at least 36” wide? *

Yes No

Part III. Entry

If there are stairs at the main entrance, is there a ramp or lift or is there an alternative accessible entrance? *

Yes No

Is the entry door at least 34” wide? *

Yes No

Does the entry door have a push pad or easy assist system? *

Yes No

Part IV. Restrooms

Is your restroom large enough to accommodate a patient who uses an adult wheelchair or scooter? *

Yes No

Are the entry doors to the restrooms are at least 36″ wide, and easy to open? *

Yes No

Does the toilet door or stall have a minimum clear opening of 32″? *

Yes No

Is there at least one open space (at least 42") to the side of the toilet? *

Yes No

Are there grab bars behind and to the wall side of the toilet? *

Yes No

Is the top of the toilet seat 17-19" from the floor? *

Yes No

Are the soap and towel dispensers 48" or less from the floor? *

Yes No

Part V. Exam Room

Yes No

Part VI. Equipment

Does your practice have access to a wheelchair scale? *

Yes No

Does your practice have a height adjustable exam table? *

Yes No

Part VII. Accommodations

Are staff members trained to assist with transfers on/off of examination table? *

Yes No

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone * (numbers only/without dashes)

Date Requested *

Group/Facility Name *

Tax ID # * (numbers only/without dash)

Group NPI # * NPI must be 10 numbers long.

Practitioner Name

First Name * Enter N/A if uploading a list of practitioners.

Middle

Last Name * Enter N/A if uploading a list of practitioners.

Suffix Enter N/A if uploading a list of practitioners.

Degree * Enter N/A if uploading a list of practitioners.

Practitioner NPI # * NPI must be 10 numbers long. Enter 9999999999 if not available.

Multiple Practitioners Upload For multiple practitioners at the same location, please upload an Excel spreadsheet with names, degrees and NPI numbers for each practitioner.

Please attach any additional supporting documents

Delete Location Address

Is this location closing? *

Yes No

Location Name * Enter N/A if not available.

Effective Date *

Street Address *

Address Line 2

City *

State *

Zip Code *

Location Phone Number (numbers only/without dashes)

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone * (numbers only/without dashes)

Date Requested *