Change Age Restrictions

Primary Care Provider (PCP) NPI # *

Provider Name

First Name *

Last Name *

Tax ID # *

Group Name *

Group NPI # *

Provider One ID Please write 'Ambetter Only' in this box if not enrolled with IHCP.

Service Location Address

Street Address *

Address Line 2

City *

ZIP / Postal Code *

State *

Provider Type (Choose One) * Primary Care Provider (PCP) Specialist

New Ambetter from Coordinated Care Age Restrictions

New Apple Health Core Connections (AHCC) Age Restrictions

New Apple Health Medicaid (AHMC) Age Restrictions

Comments

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

Additional Attachments