Provider Demographic Maintenance Form

The Provider Maintenance Form (PMF) is to be used by dental practitioners to request changes to their practice profiles.

It is critical that our members receive accurate and current data related to provider availability. Changes to provider records that are affiliated with group contracts must be reported to and submitted by the practice manager or other designated person of authority at the group. Changes to individual contracts may be made at the direction of the contracted dental practitioner. All requests must be received 30 days prior to the change/update. Submit the PMF to notify of any changes to the provider/practice name, practice/mailing address, tax identification number, phone and fax numbers, practice office hours, provider leaving/retiring, provider joining the practice, practice accepting new patients, handicapped accessibility, specialties or languages offered.

Complete all applicable sections. This form has multiple options (+) for changes. Complete only the sections applicable to the requested change(s). NOTE: This form will time out after 30 minutes of activity or inactivity and all entries made but not yet submitted will be lost.

Please note: A Network Representative will contact you if your change requires a W-9, or any additional documentation is required to complete the update.

Reason for Submitting this Form

Option 1 - Provider Level Changes

Remove a provider from a location
Name change for individual dental practitioner
License number change for individual dental practitioner
Add or change provider's degree
Update or add your Individual NPI
Add or change provider's language(s) spoken (other than English)
Add or change your provider specialty or type

Please note: Specialty changes may require additional follow-up if not already approved by credentialing.
CLICK HERE to make one or more of the above changes.

Option 2

Practice changes (these changes apply to all providers currently practicing under the Tax Identification (TIN) provided).

Note: If additional information is required you will be contacted by a Network Representative.

Change your Tax Identification Number/IRS Name (TIN)
Change in ownership for an existing practice
Change your practice address or phone/fax number
Change your practice name
Add a new location
Close a practice location
Change your billing or correspondence address
Change your office hours or days of operation
Change in your acceptance of new patients
Update or add your Organizational Clinic or Corporate NPI
Update or add your email address(es)
Add or change language(s) spoken by qualified medical interpreter

CLICK HERE to make one or more of the above changes.

Welcome to GOLDEN WEST

Provider Maintenance Form

Reason for Submitting this Form

Option 1

Option 2

Option 3

General information (mandatory fields – must be completed to submit form)

General information (mandatory fields – must be completed to submit form)

Remove a provider from a location

Name change for individual dental practitioner

License number change for individual dental practitioner

Add or Change Provider's Degree

Update or add your Individual NPI

Add or change provider's language(s) spoken

Add or change your provider specialty or type

Change your Tax Identification Number/IRS Name (TIN)

Change in ownership for an existing practice

Change your practice address or phone/fax number

Change your practice name

Add a new location

Close a practice location

Change your billing or correspondence address

Change your office hours or days of operation

Change in your acceptance of new patients

Update or add your Organizational Clinic or Corporate NPI

Update or add your email address(es)

Add or change language(s) spoken by qualified medical interpreter

Attachments