Employee Assistance Program (EAP) Update Form

Network Applying to:

Provider Info

If your last name has changed, please email EAP_PR@ndbh.com and we can update our records.

First Name

Middle Name

Last Name

Individual NPI:

Individual Provider Email

Social Security Number

Last 4 of Social Security Number

Provider Cell Phone:

Education Information

Official Name of School

Degree Earned

Graduation Date

Areas of Speciality

Please select all areas of specialty where you are clinically experienced, practice regularly, and which are within the scope of your license and training/certifications.

Note: To change specialty information please use the status field, please do not click "remove" you will lose all information and could cause issues with your file.

Specialities

Status

Specialty:

To add more specialties please click link below.

Special Services

Status

Special Populations

Languages

Status

What language(s) other than English do you speak?

List other languages:

Age Groups

Status

Please select an Age Group with whom you work:

Race and Ethnicity

In accordance with the provisions of Title VI of the Civil Rights Act of 1964, New Directions does not discriminate on the basis of race, color, or national origin. Please be aware that this information is beneficial to our members as some members feel more comfortable with a provider of the same ethnicity or cultural background.

Status

Optional:

Hidden

Account ID (Hidden)

Please include the following information for all practices which you may be providing services.

Address Update Instructions

A primary address is required for each Tax ID #. If you only have one practice location, it will be the primary address. All additional practice locations with the same Tax ID are considered secondary addresses. List the billing address for each Tax ID in the billing address portion of the form.

Each address has the following update options. Please understand what each update option for addresses means:

Yes, this is Active- This will keep the address and Tax ID # active in our systems for billing purposes.

No, this should be Deactivated- The provider will no longer be able to bill for dates of service using the address and Tax ID # as of 30 days from today.

Unsure, about Status of Address- No changes to the address and Tax ID # will be made in our systems at this time. An email verification will sent to the provider to verify current addresses and Tax ID #.

If you are a group practice making updates on behalf of a provider, please only update the applicable address information to your group practice for the provider.

You will not be able to edit the practice name, TIN, practice address. If you need to make changes to any of this information you will need to inactivate the location and create a new entry with the correct information. You may update phone, fax, and email without needing to inactivate.

I have read and understand how each address update option impacts billing and I verify I am able to provide these updates on behalf of the provider.

Name of person filling out form:

Position of person filling out form:

Email of person filling out form:

Primary Address

Address Type

Address Status

Termination Date

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Start Date

Tax ID (TIN/EIN)

Please do not place a - in your Tax ID number

Provides Telehealth

Address ID

New Primary Address

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Provides Telehealth

Start Date

Tax ID (TIN/EIN)

Please do not place a - in your Tax ID number

W9 Upload

Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one. If you need a new form, it can be downloaded here: https://www.irs.gov/pub/irs-pdf/fw9.pdf

Primary Schedule

Days of the Week

Start Time

End Time

Billing Address

Address Type

Address Status

Termination Date

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Phone:

Fax:

Tax ID

Address ID

New Billing Address

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Phone:

Fax:

Tax ID

Please do not place a - in your Tax ID number

Other addresses?

Secondary Address(es)

Address Type

Address Status

Termination Date

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Start Date

Tax ID (TIN/EIN)

Please do not put a - in your Tax ID number.

Provides Telehealth

Address ID

Do you have any other addresses?

New Address(es)

Address Type

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Start Date

Provides Telehealth

Tax ID (TIN/EIN)

Please do not put a - in your Tax ID number.

W-9 Upload

Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one.

Secondary Schedule

Days of the Week

Start Time

End Time

Acknowledgement

I hereby certify and attest, by checking this box I have reviewed all the information above and the information is true and accurate. I understand that any information provided pursuant to submission of this provider data that is subsequently found to be untrue and/or incorrect could result in my termination from the New Directions’ behavioral health network. By checking here, you are verifying that you are the provider who completed this form or, if completing for a provider, that you have the authority to complete this form on behalf of that provider.

I agree

Todays Date

Name

Contact Information