Laserfiche WebLink
Wash ington State " ......------, <br />Health CareKuthority / <br />Find a Provider Form <br />ProviderOne Find a Provider Modification Form <br />Provider Name: <br />NPI : <br />Would you like to be listed in our ProviderOne Find a Provider site as a provider accepting new <br />patients? <br />Yes D No D <br />Signature: Date: <br />Print Name Here: <br />"This form is to comply with Washington Administrative Code fYVAC) 182-502-0016 and the Core Provider Agreement which <br />requires providers to notify the agency of any changes to the provider's application or contract. For any additional changes <br />please contact provider enrollment at 1-800-562-3022 Ext 16137 or providerenrollment@hca.wa.gov. <br />I <br />Please email this form to providerenrollment@hca.wa.gov <br />HCA Contract No. «Contract_Number» Page 10 of 12