Change the Role (PCP or Specialist) of a Current Provider Please complete the following information to change a participation provider's role (PCP or Specialist) at their affiliated location.Effective Date* MM slash DD slash YYYY Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Provider NPI* Provider Name* Primary Specialty* Secondary Specialty Emergency/Urgent Care Provider* Yes No Practice Name* Practice NPI (if applicable) Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Current role at this location* PCP Specialist New role at this location* Specialist New role at this location* PCP Specialty* Name of Provider Assuming Panel* Provider NPI* Is the provider accepting new patients at this location?* Yes No Provider's hours at this location* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours* Custom Open 24 Hours Sunday Open* : Hours Minutes AM PM AM/PM Sunday Close* : Hours Minutes AM PM AM/PM Monday Hours* Custom Open 24 Hours Monday Open* : Hours Minutes AM PM AM/PM Monday Close* : Hours Minutes AM PM AM/PM Tuesday Hours* Custom Open 24 Hours Tuesday Open* : Hours Minutes AM PM AM/PM Tuesday Close* : Hours Minutes AM PM AM/PM Wednesday Hours* Custom Open 24 Hours Wednesday Open* : Hours Minutes AM PM AM/PM Wednesday Close* : Hours Minutes AM PM AM/PM Thursday Hours* Custom Open 24 Hours Thursday Open* : Hours Minutes AM PM AM/PM Thursday Close* : Hours Minutes AM PM AM/PM Friday Hours* Custom Open 24 Hours Friday Open* : Hours Minutes AM PM AM/PM Friday Close* : Hours Minutes AM PM AM/PM Saturday Hours* Custom Open 24 Hours Saturday Open* : Hours Minutes AM PM AM/PM Saturday Close* : Hours Minutes AM PM AM/PM Additional Information Required to Process PCP Role Change RequestName of Provider assuming panel* Provider NPI* Specialty (Must match the provider's PCP role)* Details for the person submitting the formName* Title* Phone Number*Email* Date* MM slash DD slash YYYY CAPTCHA