TIN Updates
To download the forms needed, click the link below.
Additional Resources
Visit the TIN Add Documents page for more information and resources.
Go to TIN Add Documents
Email
*
example@example.com
Provider's Name
*
First Name
Last Name
Provider NPI #
*
Type of Change* Fees apply for adding TINs
*
Switching TINs
Add an additional TIN
Term an Old TIN
Start Date of Change
*
-
Month
-
Day
Year
Date
End Date of Old TIN
-
Month
-
Day
Year
Date
New Legal Business Name
New Tax ID
New Group NPI
Old Tax ID
New Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a secondary location?
*
Yes
No
Secondary Practice Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number
*
-
Area Code
Phone Number
New Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Phone
-
Area Code
Phone Number
Billing Fax Number
-
Area Code
Phone Number
Office Hours
*
Age Limits
*
0-120 (All Patients)
18+ (Adults Only)
0-18 (Children Only)
Gender Limits
*
Both- Men & Women
Men Only
Women Only
Primary Hospital
If None, type "None"
Upload New W9
Browse Files
Cancel
of
Upload New Provider Relations Packet
Browse Files
One is Required for Each TIN - We cannot use on file items.
Cancel
of
Upload Tiopa Addendums (BOTH Location and Provider)
Browse Files
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of
Important Document Copies: SSN, Driver's License, COI, (if applicable) CLIA, (if applicable) Radiology Cert
Browse Files
Please upload a copy of each file listed to the left.
Cancel
of
Allied Health Professional Collaborative Agreement Protocols
Browse Files
Cancel
of
Submit
Should be Empty: