Address Change | Buckeye Health Plan

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)

Please use the “Add an Additional Location” option if this is a brand new location.

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 *

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number * (numbers only/without dashes)

Date Requested *

Group/Facility Name *

Group Tax ID # * (numbers only/without dash)

Group NPI # * NPI must be 10 numbers long.

Location Name * Enter N/A if not available.

Street Address *

Address Line 2

City *

State *

Zip Code *

Location Phone Number * (numbers only/without dashes)

Location Fax Number (numbers only/without dashes)

Primary Care Clinic? *

Yes No

Patient Capacity

Please use the New Provider Data Form or Standard Roster Template to submit the names of all practitioners that should be linked to this new location.

Member Access

Scheduling Phone *

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 *

Does the location offer telehealth services? *

Yes No

Language Services

Does the location have access to Language Line services? *

Yes No

Does the location offer translation services for written materials? *

Yes No

Does the location have linguistic capabilities, other than English, including American Sign Language, offered by the provider or a skilled medical interpreter at the location? *

Yes No

Which Additional Languages? *

Electronic Health Records

Does the location use electronic health records (EHR)? *

Yes No

EHR vendor name *

Is the location a member of a health information exchange (HIE)? *

Yes No

Location Accessibility

Is the location on an accessible public transportation route? *

Yes No

Buckeye Health Plan is committed to providing equal access to quality health care and services that are physically and programmatically accessible for our members with disabilities and their companions. Buckeye aims to transition health-care delivery into a fully accessible system for our members, while improving the accuracy and transparency of disability access data in Buckeye’s provider directories. Members are able to view a location’s detailed disability access information using the online Find a Provider tool, as well as filter for a provider based on their disability access needs.

Access Survey

Group/Facility Name *

Tax ID # * (numbers only/without dash)

Group NPI # * NPI must be 10 numbers long.

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 *