Skip to content
Need help?
1-888-327-0671 (TTY: 711)
McLaren Health Plan
Main Menu
About Our Plans
Health & Wellness
Find Help
Community Calendar
McLaren CONNECT Login
Members
Agents
Providers
Make a Payment
About Us
Contact Us
Search
About Our Plans
For Members
Back to Top
For Providers
McLaren CONNECT Login
Document or Resource
Provider Change Form
McLaren Health Plan: Your Choice for Michigan Health Insurance
/
Documents and Links
/
Provider Change Form
The embedded form could not be loaded. Please refresh the page or try again later.
Provider Change Form
Reminder: All changes must be submitted to MHP at least 60 days prior to effective date, to ensure systems are appropriately updated.
Note:
Fields marked with an
*
indicates required field.
Current Date:
*
Effective Date of Change:
*
Provider First Name:
*
Provider Last Name:
*
Provider Credentials:
*
Individual NPI Number:
*
Group or Office Name:
*
Group NPI Number:
Type of Change (select applicable changes):
*
Billing - Payto Information
Change of Office - physical - Location
Change of Provider Specific Information
Add or Term a Provider
Provider Specific Information
Current Provider ID Number:
Change to Provider ID Number:
Current Provider Name Information:
Provider Name Change or Correction:
Current Provider Board Certification:
Change to Provider Board Certification:
Current Provider Specialty Type:
Change to Provider Specialty Type:
Current Hospital Affiliation(s):
*
Change to Hospital Affiliation:
Current Hospitals with Admitting Privileges:
Change to Hospitals with Admitting Privileges:
Current CAQH Number:
Change to CAQH Number:
Current CHAMPS Number:
*
Yes
No
Cultural and Linguistic Training Complete (CLAS):
*
Yes (attestation required)
No
Current Language Information:
Change to Language Information:
Office Physical Location
Current Street Address:
*
Change to Street Address:
Current Building - Suite Number:
Change to Building - Suite Number:
Current City:
*
Change to City:
Current State:
*
Change to State:
Current Zip Code:
*
Change to Zip Code:
Current County:
*
Change to County:
Current Telephone Number - (xxx) xxx-xxxx:
*
Change to Telephone Number - (xxx) xxx-xxxx:
Current Fax Number - (xxx) xxx-xxxx:
*
Change to Fax Number - (xxx) xxx-xxxx:
Office Website URL:
Current Office Hours
Use “Start/End” for operating hours. Use “Lunch” only if applicable.
Monday
Start
End
Lunch
–
Tuesday
Start
End
Lunch
–
Wednesday
Start
End
Lunch
–
Thursday
Start
End
Lunch
–
Friday
Start
End
Lunch
–
Saturday
Start
End
Lunch
–
Sunday
Start
End
Lunch
–
Requested Changes to Office Hours
Only complete rows/days that are changing.
Monday
Start
End
Lunch
–
Tuesday
Start
End
Lunch
–
Wednesday
Start
End
Lunch
–
Thursday
Start
End
Lunch
–
Friday
Start
End
Lunch
–
Saturday
Start
End
Lunch
–
Sunday
Start
End
Lunch
–
Billing Pay To Information
(Must submit current W-9 with change requests)
Current Pay To Provider Information:
Pay To Provider Information Changes:
Current Billing Address Information:
Billing Address Information Changes:
Current Tax Identification Number:
*
Tax Identification Number Changes:
Changes to Billing or Pay To Information section require submission of W-9 with request.
*
Was an updated W9 uploaded with this change?
*
Yes
No
Upload of CLAS Attestation
Name of Person Submitting Request
First Name:
*
Last Name:
*
Title:
*
Phone Number - (xxx) xxx-xxxx:
*
Email:
*
Comments:
Captcha
*
No additional information is available for this resource.
Page Loading
Loading...