Provider Contact Change Form
Connolly is a Recovery Audit Contractor (RAC) for CMS. While providers should always keep their contact information current with their
Medicare Administration Contractor (MAC) as well as the National Provider Information (NPI) Registry, the contact information below
will help ensure RAC-related information from Connolly is addressed appropriately.
Instructions
Instead of this form, the same changes can also be made online through Connolly’s Provider Portal found at www.Connolly.com/RAC
1. This form must be completed and submitted electronically therfore, printing is disabled – do not fax or mail.
2. Once all sections are completed, please double-check it for accuracy. Note: Only one contact is permitted per
address type, and this change form cannot be processed without the required fields in Section A.
3. Save the completed form to your computer with the provider name and current date as the document name (e.g.
GraceHealthcare_07252014)
4. Attach the form to an email and send to [email protected] with ‘Contact Change Form’ in the subject. Your
change will be processed within 2 business days.
5. Note: If you represent multiple facilities/providers, please use the ‘Multi-provider Spreadsheet’ found at the above
web address – rather than submitting multiple copies of this form.
Required Information
A.
Provider Name:______________________________________________ Provider Medicare ID:____________________
Tax Identification Number: __________________________
NPI Number: ___________________
*Person Submitting this form: ___________________ Phone Number for any Questions: ____________________
Is this change being made subsequent to an ownership change or divestiture?
YES
NO
Contact for Medical Records
This is where Additional Documentation Requests (ADR) will be mailed, and courtesy reminders faxed.
Contact Person (to the attention of): __________________________________ Title: _____________________
Address Line 1:_________________________________________ Phone:______________________
Address Line 2:_________________________________________ Fax: ______________________
Address Line 3:_________________________________________ Email:______________________
City:__________________
State:____
Zip Code: _______
B.
Check here to
Contact for Finance
use same info
This is where review results letters and reimbursement checks (if applicable) will be mailed.
as Section B.
Contact Person (to the attention of): __________________________________ Title: _____________________
Address Line 1:_________________________________________ Phone:______________________
Address Line 2:_________________________________________ Fax: ______________________
Address Line 3:_________________________________________ Email:______________________
City:__________________
State:____
Zip Code: _______
C.
Check here to
Facility Location
use same info
This is the physical location of the facility/provider.
as Section B.
Contact Person (to the attention of): __________________________________ Title: _____________________
Address Line 1:_________________________________________ Phone:______________________
Address Line 2:_________________________________________ Fax: ______________________
Address Line 3:_________________________________________ Email:______________________
City:__________________
State:____
Zip Code: _______
D.
E.
Discussion Response
Check here to
use same info
as Section B.
Contact Person (to the attention of): __________________________________ Fax: _____________________
Note: If Section E is completed, the response to any Discussion Requests will automatically be faxed to this contact. If the
fax attempt is unsuccessful, it will automatically drop to mail by default to the contact in Section C.
*By submitting this form, the person named in Section A acknowledges they are authorized to request these changes on
behalf of the facility.
ICF12032014