Independent Contractor Change of Status Please enable JavaScript in your browser to complete this form.Your Name *Name of person completing form Your Email *Date *Date form completedFacilityProvider Provider Data New ProviderModify ProviderTerminating ProviderName *FirstLastBusiness Name *Legacy Care Email Address *Cell Phone Number *Assigned FacilityDate on NoticeLast Date of ServiceStart Date *Provider NPI # *Found on credentialing packetMD Coder AccessAddMD Coder Access RemoveMD Coder AccessAddRemovePayment MethodRVUMSOPayment RatePayment Rate Certificate of InsuranceLegacy Care Credentialing DateLegacy Care Client Facility Placement DateRole *PhysicianNPPAMedical Director YesNoStart DateEnd DateAssigned Facility Invoiced AmountMonthly/Hourly rate billed by Legacy CareTimesheet Required for InvoiceYesNoInvoice Recipient NameFirstLastInvoice Recipient EmailEmail address to receive invoice for monthly stipend from Legacy CareStipend Amount Monthly/Hourly rate provider receives Collaborating APP NameFacility NameAddDeleteStart DateEnd DateCollaboration StipendNameFacility NameAddDeleteStart Date End DateCollaboration StipendNameFacility NameAddDeleteStart Date End DateCollaboration Stipend NameFacility NameAddDeleteStart Date End DateCollaboration StipendName Facility NameAddDeleteStart Date End Date Collaboration Stipend NameFacility Name AddDeleteStart Date End DateCollaboration Stipend Facility DataNew Facility to Legacy CareTerm from Legacy CareNew Facility to current ProviderTerm from Legacy CareFacility Name Per CMS (Parent Entity) *Full Facility name, per CMS, no abbreviations Record IDLocated in SalesForcePhone Number of Facility *Address of Facility Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStart Date *Name of Provider *Facility NPI # *Date on NoticeLast Date of ServiceFacility Type *SNFNFALILAcuteIRFCCRCHomeChoose all that applyChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceOptional NotesSubmit
