Previous Contact Information

• Contact information is displayed from latest Enrollment or Maintenance item. To update the information, edit the allowable field(s).

Contact Type - The current Agent of Service and Credentialing contacts are required.

• If information needs to be updated, select the Contact Type from the drop down box.

• Agent of Service

• Contact Type for Agent of Service is required for all Category Types.

• The individual designated to receive legal documents and tax notices for a business entity  is responsible for ensuring important correspondence and legal notices are received

• Credentialing Contact

• The individual designated to receive any updates or information regarding Medicaid enrollment.  This person is recognized as the contact  for a particular provider or group and can update the provider’s  information.

• Pay-To/1099 Contact

• The individual designated to receive information regarding 1099 forms.

• Is required for all Enrollment Category Types:  Individual, Group & Entity.

Contact Name

• First and last name is pre-populated.

Mobile Number

• If Mobile Phone is selected as the Preferred Contact Method, a Mobile Number must be entered

Office Phone Number

• If Office Phone Number is selected as the Preferred Contact Method, an Office Phone Number must be entered

• Enter the Contact Person’s extension if applicable

Fax Number

• If Fax number is selected as the Preferred Contact Method, a Fax number  must be entered

Email Address

• If Email address is selected as the Preferred Contact Method, an Email address must be entered

“Add to Grid” button will validate field requirements and will add the information into the grid

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page