PROVIDER UPDATE FORM If you wish to update your specialty, membership needs, or any other information, please complete and submit the form below. PROVIDER NAME NPI NUMBER SPECIALTY GROUP PRACTICE NAME Check All That Apply: I want to terminate the above provider(s) membership from The Mount Sinai IPA. I want to terminate the above provider(s) participation with the following plan(s): 1199 Access Medicare Aetna Affinity Amerigroup Amidacare ChoiceCare/Humana Cigna Empire BCBS GHI HealthFirst HIP Magna Care Metroplus Multiplan Oxford/UHC POMCO Senior Whole Health VNS NOTE: This action requires a signed and dated letter from the provider. Please attach by clicking "upload" at the bottom of the form. I want to disassociate provider(s) from the Mount Sinai IPA fee schedule. (Note: This action may terminate provider participation entirely if the payer does not offer an individual agreement). I want to enroll the above provider(s) in the following plans: 1199 Access Medicare Aetna Affinity Amerigroup Amidacare ChoiceCare/Humana Cigna Empire BCBS GHI HealthFirst HIP Magna Care Metroplus Multiplan Oxford/UHC POMCO Senior Whole Health VNS I want to update the above provider(s) specialty. ADD SPECIALTY REMOVE SPECIALTY NOTE: This action requires an updated board certificate. Please attach by clicking "upload" at the bottom of the form. I want to update the name of the above group practice to: NOTE: This action requires an updated W9. Please attach by clicking "upload" at the bottom of the form.SUBMITTED BY (Click "upload" to attach supporting documentation).File Drop files here or Select files Accepted file types: doc, docx, pdf, jpg, Max. file size: 10 MB, Max. files: 6. CAPTCHA Δ