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Provider Demographics & Information Changes ____________________________________________________
This section applies to all contracted providers and vendors . Submitting Demographic Changes or Corrections
Changes should be submitted 60 days in advance or as soon as possible , on your office letterhead and emailed to Network Services at HTHProviderRelations @ hometownhealth . com or faxed to ( 775 ) 982-8003 .
Please include your tax identification number on all correspondence to ensure timely processing of all changes .
Demographic Changes / Corrections consists of such items as :
• Practice Name
• Billing Address
• Practice Address
• Telephone Number
• Fax number
Tax Identification Number changes include :
• Terminating an existing tax identification number
• Adding a new tax identification number
• Correcting an existing tax identification number
Note : Any name or tax identification number changes must include a revised W-9 . Additions include :
• Adding a new provider to the practice
• Opening an additional location
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