Legacy Employee Provider Change Of Status Please enable JavaScript in your browser to complete this form.Your Name *Name of person completing formYour Email *DateDate form completedFacilityProviderProvider DataMultiple ChoiceNew ProviderModify ProviderTerminating ProviderName *FirstLastHire DateLegacy Care Email AddressMust be @lgslegacycare.comCell Phone #Assigned FacilityProvider NPI # *Found on credentialing packetDate on NoticeLast Date of ServiceMD Coder AccessAdd and clone favorites RemoveRolePhysicianNPPACollaborating APP Name Facility Name AddDeleteCollaboration Stipend Name Facility NameAddDeleteCollaboration StipendName Facility Name AddDeleteCollaboration StipendName Facility Name AddDeleteCollaboration Stipend Name Facility Name AddDeleteCollaboration Stipend Name Facility Name AddDeleteCollaboration Stipend Facility DataNew Facility to Legacy CareTerm from Legacy CareFacility Name Per CMS (Parent Entity)Full Facility name, per CMS, no abbreviationsRecord IDLocated in SalesForcePhone # of FacilityAddress of FacilityAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStart DateName of ProviderDate on NoticeLast Date of ServiceFacility NPI #Facility TypeAcuteChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceChild NameRecord IDLocated in SalesForceOptional NotesSubmit
