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									                      First Health Services – Nevada Medicaid and Nevada Check Up

                               Provider Information Change
Providers are required to notify Nevada Medicaid within five days of knowledge of changes in professional
licensure, facility/business/practice address, provider group membership or business ownership. You may use
this form to report these and other changes to your information on file with Nevada Medicaid.

The provider or authorized representative must initial the bottom of page 1, and sign and date page 2.
Use additional forms if needed to record all changes. Attach a copy of required enrollment documentation
(e.g., certifications and licenses) only if there are changes or additions.

Address, phone, fax, email, NPI, Medicare and contact name changes may be faxed to (775) 784-7932.
All other changes must be mailed to First Health Services, Provider Enrollment, PO Box 30042, Reno
NV 89520-3042. If you have questions, please contact the Provider Enrollment Unit at (877) 638-3472 or
email nevadamedicaid@fhsc.com.


1. Enter the name of the provider/facility reporting changes. (required) ______________________________
2. Describe the change(s) you are reporting. (required) _________________________________________
    ____________________________________________________________________________________
    ____________________________________________________________________________________
3. On what date is the change(s) effective? (required) ___________________________________________
4. Which NPIs/APIs are affected? (required) __________________________________________________
    ____________________________________________________________________________________

Complete fields below only if there are changes. Leave all other fields blank.

5. National Provider Identifier (NPI): ___________________________________________________
    Taxonomy Code(s): ________________________________________________________________
    A list of taxonomy codes is available at www.wpc-edi.com/taxonomy.

6. New/Changed CLIA number: _____________________________________________________
    New/Changed DEA number: ____________________________________________________________
    New/Changed mammography certification number: _________________________________________
    New/Changed Medicare number: __________________________________________________
    New/Changed Medicare carrier name: _____________________________________________
    Other certification: ____________________________ New/Changed number: _______________

7. IRS Name: _______________________________________ Effective Date: _________________

   Tax ID Number: ___________________________________ Effective Date: _________________
When reporting IRS name or Tax ID Number changes, attach IRS form CP575, SS-4, or W-9 showing the new
name and/or number.

FH-33
09/23/08                     º _______ Provider Initials (required)                              Page 1 of 3
8. First Health Services can record up to four different addresses for each provider. To add or change an
address, check the relevant address box and complete the fields that follow. Use additional forms if needed
to record all address changes (you can add/change one address per FH-33 form).
    q Service Address: This is the physical location of your practice/business/facility (cannot be a P.O. box).
    q Mail-To Address: Written correspondence other than Remittance Advices is mailed to this address if supplied.
    q Remittance Advice Address: Paper Remittance Advices, will be mailed to this address if supplied.
    q Pay-To Address: Paper checks will be mailed here while Electronic Funds Transfer (EFT) testing is performed.

    Address: ________________________________________________________________________________

    City: ____________________ State: _____ Zip Code: ____________County (not Country): _____________

9. Phone: _________________________ Fax: _________________________ TDD: _________________

10. E-mail Address: _____________________________________________________________________

11. Provider Contact Name: ________________________________________________________________

12. Complete the following to add or exclude providers from a group.
    Provider Group’s NPI: _________________________________________________________________
    q Add provider to the group      q Exclude provider from the group
    Provider NPI: _____________________ Provider Signature: __________________________________
    q Add provider to the group      q Exclude provider from the group
    Provider NPI: _____________________ Provider Signature: __________________________________
    q Add provider to the group      q Exclude provider from the group
    Provider NPI: _____________________ Provider Signature: __________________________________

13. Electronic Funds Transfer (EFT) Authorization: I hereby authorize First Health Services and its
subsidiaries to transfer my Nevada Medicaid and Nevada Check Up payments to the personal or business bank
account shown below. I also authorize any necessary debit entries to correct payment errors. I understand the
payments made through electronic funds transfers will be from Federal and State funds and that any falsification,
or concealment of a material fact, may be prosecuted under Federal and State laws. This agreement will remain in
effect until I notify First Health Services or the banking institution otherwise. I understand that First Health
Services and/or my banking institution may also cancel this agreement at any time. All such cancellation notices
must be made in writing and acted upon in a reasonable and timely manner. I understand that cancellation of
an EFT account may result in termination of my Nevada Medicaid enrollment.

   Business or Personal Bank Account Number: _______________________________________________

   Authorized Signature: ____________________________________________ Date: ________________




FH-33                                                                                                Page 2 of 3
09/23/08
Declaration – (Required)
I declare under penalty of perjury under the laws of the State of Nevada that the information in this document
and any attachments are true, accurate and complete to the best of my knowledge and belief. I declare that I
have the authority to legally bind the Provider. I understand that Nevada Medicaid, Nevada Check Up and
First Health Services will rely on this information and that this form will be incorporated into and become a
part of my provider information on file with the First Health Services and the State of Nevada. I understand
that any change to the facts presented on this form must be reported to Medicaid within five days or
my Provider Contract with Nevada Medicaid and Nevada Check Up is subject to immediate termination.
I understand that I am responsible for the presentation of true, accurate and complete information on all
invoices submitted to First Health Services. I further understand that payment and satisfaction of these
claims will be from federal and state funds and that false claims, statements, documents, or concealment of
material facts may be prosecuted under applicable federal and state laws.

______________________________________________                   __________________________________
Signature (blue or black ink only)                               Date

______________________________________________                   __________________________________
Print Name                                                       Social Security Number




                                       Print                Reset



FH-33                                                                                              Page 3 of 3
09/23/08

								
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