Instructions for Completing the 1199SEIU Provider Demographic Information Change Request Form
Provider name: Practitioner or entity requesting the change
Email: Current email address
Specialty: Current specialty or practicing specialty on file with the Benefit Funds
Area of Interest (Optional): A Specialized medical (dental or behavioral health) field of practice or provider expertise for which the provider possesses training outside of their designated specialty. For example, a Dermatologist might list “Mohs Surgery” or a Behavioral Health provider might list “anxiety”.
NPI: Current individual National Provider Identifier (NPI)
Tax ID: Current Tax Identification Number (TIN)
Current Provider Information Section: This section identifies the provider requesting the change.
Participating provider: Defined as a provider who is credentialed by, and contracted directly with, the Benefit Funds. If you are unsure of your participation status, please visit the Funds’ website at www.1199SEIUFunds.org and click on the “Find A Provider” link on the homepage to access our online directories.
Non-participating provider: Defined as a provider who is not credentialed by, and does not have a contract with, the Benefit Funds. If you wish to become a participating provider, please visit the Funds’ website at www.1199SEIUFunds.org, click on the “For Providers” tab and then click on the link “Please join us as a participating physician.” This will lead you to the “Become A Provider” page. Follow the instructions on this page.
Group practice: Association of healthcare professionals listed under the same TIN who share premises and other resources
Individual provider: Solo practitioner
Institution/Facility: Entity, vendor or hospital (non-individuals)
Date change will take effect: Date the change will become effective. Please note: 1199SEIU Provider Demographic
Information Change Request Forms should be submitted 60 days in advance of a requested update.
Provider Change Information Section: This section identifies the type of provider requesting the change.
Add TIN: Defined as adding a new Tax Identification Number (TIN) and unique billing address to the information currently on file with the Benefit Funds.
• To add a TIN, you must complete the “New Service Information” and “New Billing Information” sections under the“New Demographic Information” section. A new W-9 form must be submitted for the new TIN.
Deactivate TIN: Defined as terminating a Tax Identification Number (TIN), effective on a specified date.
• To deactivate a TIN, you must complete the “Old Service Information” section, if applicable, and the “Old BillingInformation” section under the “Old Demographic Information” section. Please ensure that the TIN to be deactivatedis listed.
Change TIN: Defined as terminating the current Tax Identification Number (TIN) and activating a replacement TIN, effective on a specified date.
• To change a TIN, you must complete the “New Demographic Information” and “Old Demographic Information”sections. A new W-9 form must be submitted for the new TIN.
Type of Change Section: This section identifies the type of change being requested. You may check more than one box.
The following are definitions and instructions for each type of change to help you complete the form:
1199SEIU Benefit Funds
Add billing address: Defined as adding a billing address where checks are mailed without a change to the Tax Identification Number (TIN), effective on a specified date.
• To add a billing address, you must complete the “New Demographic Information” section. A new W-9 form must besubmitted with the new billing address.
Change billing address: Defined as changing the payment address where checks are mailed without a change to the Tax Identification Number (TIN), effective on a specified date.
• To change a billing address, you must complete the “New Demographic Information” and “Old DemographicInformation” sections (new and old billing information only). A new W-9 form must be submitted with the new billingaddress.
Add service address: Defined as adding a new practicing address to the Benefit Funds’ provider lists and directories.• Participating providers ONLY: To add a new service address, you must complete the “New Service Information”
section under the “New Demographic Information” section. Please ensure that the Tax Identification Number (TIN)is listed.
• Non-participating providers: The Benefit Funds do not maintain service locations for non-participating providers.
Delete service address: Defined as removing a service location, from the Benefit Funds’ provider lists and directories. Please ensure that you have at least one current service location on file by checking the Funds’ website at www.1199SEIUFunds.org and using the Provider Directory.
• Participating providers ONLY: To delete a service location, you must complete the “Old Demographic Information”section (service information only). No W-9 form is required. Please ensure that the Tax Identification Number (TIN)is listed.
• Non-participating providers: The Benefit Funds do not maintain service locations for non-participating providers.
Change service address: Defined as updating a practicing address to the Benefit Funds’ provider lists and directories.
• Participating providers ONLY: To change a service location, you must complete the “New Service Information”section under the “New Demographic Information” section. Please ensure that the Tax Identification Number (TIN)is listed.
• Non-participating providers: The Benefit Funds do not maintain service locations for non-participating providers.
Change name (group or physician): Defined as updating the group practice’s name and specifying if this change affects the billing or pay-to information. If the change affects the billing location, a new W-9 form must be submitted with the request.
• To change the name of a group practice, you must complete the “New Demographic Information” section (serviceinformation only) and submit a new W-9 form, if applicable.
Change or add hospital affiliation: Defined as updating the hospital affiliation where a provider has admitting privileges or changing a Member Choice network affiliation as listed in the Benefit Funds’ directories. A copy of a current (within 180 days) hospital appointment letter is required.
Add specialty: Defined as adding a new specialty to the specialty or specialties that are on file with the Benefit Funds. In addition to the completed 1199SEIU Provider Demographic Information Change Request Form, a copy of a current board certification certificate, where applicable, or curriculum vitae (CV) is required.
Add language: Defined as adding a language, or languages, spoken in the provider’s office.
Delete language: Defined as deleting a language, or languages, no longer spoken in the provider’s office.
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For providers who are contracted with Aetna Signature Administrators Network:
Aetna Signature Administrators (ASA) providers located within NY, NJ, CT and PA requesting to update their data must contact Aetna directly at (888) MD-AETNA (888-632-3862).
Aetna Signature Administrators (ASA) providers located outside of NY, NJ, CT and PA must complete the 1199SEIU Provider Demographic Information Change Request Form to update Tax Identification Number (TIN) and other billing information only. These providers must contact Aetna directly at (888) MD-AETNA (888-632-3862) for all other changes.
For providers who are contracted with MedFocus:
Providers contracted with MedFocus who want to update their demographic information must contact MedFocus directly at (800) 398-8999.
Additional Information
Print name and title of authorized signature: The name and title of the provider who is requesting the change or the individual authorized to act on behalf of the provider
Authorized signature: Signature of the provider or the individual authorized to make changes on the provider’s behalf
Date: Date of when the form was signed
Title: Title of the individual signing the form
Email: Email address of the individual signing the form
Telephone: Telephone number of the individual signing the form
Fax: Fax number of the individual signing the form
Authorized Name and Title Section
New Demographic Information Section
New Service Information: New service address that is replacing existing practice information or being added to the list of current practice locations
New Billing Information: New billing address where checks or remittance advice should be mailed
Old Demographic Information SectionOld Service Information: Previous or current service information, including practice location or locations
Old Billing Information: Previous or current billing address or addresses
