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Changes & Additions

The following are options for CBO Enrollment changes and additions:

Any and all changes in enrollment status must begin with the IMPACT System.

Click here to view the Impact Enrollment Guidelines

Name changes

Individuals who have had a legal change in their name must change their name in the credential and enrollment systems for reimbursement of services to continue without disruption. First go to IMPACT to make changes. Then click the name change below and download/complete the EI Service Matrix form. A copy of the legal document that verifies the name change must be included with this submission.

-Name Changes-

Address changes

Individual providers who need to make a change in their payment address for billing purposes must first go to IMPACT to make changes. Then use the EI Service Matrix form, contained in the link below, in order to make such a change.

Provider Agencies that need to make a change to the payment address for the agency for billing purposes must first go to IMPACT to make changes. Then use the EI Service Matrix form and include a typed list of all EI providers employed with the agency that are affected by the address change.

-Address Changes-

Adding Individual Enrollment

Providers who are currently enrolled in the EI Central Billing Office through one or more agencies may enroll themselves as an independent/private provider. Only providers who are currently enrolled should use these forms for enrolling independently. First go to IMPACT to make changes. Then complete the Payee Agreement and Service Matrix contained in the link below. If an individual provider terminates employment with the agency(s) in order to provide independent services, a letter should accompany the forms indicating that the employment ended and the last date of employment. This allows Provider Connections to inactivate enrollment for agencies where providers are no longer employed.

-Adding Individual Enrollment-

Adding Agency Provider Status to an Established Agency

Individuals who are currently enrolled in the EI Central Billing Office independently and/or with another agency may enroll themselves as a provider for another agency by first going to IMPACT to associate with the agency. Then complete the Service Matrix form contained in the link below.

Use the instructions provided to complete the documents appropriately.

-Adding enrollment to Established Agency-

Creating a New EI Agency Provider

Individuals that are currently enrolled in the EI Central Billing Office independently and/or with another agency who would like to create a new agency must first go to IMPACT to establish the agency. Then complete the Payee Agreement and Service Matrix contained in the link below. For example, individuals enrolled as independent providers using their social security number as the taxpayer ID# who wish to employ other providers must establish themselves as other than an individual provider,

OR

Agencies in which the agency name and FEIN has changed must first go to IMPACT to make changes. Then complete the forms contained in the link below and attach a list of all provider enrolled to bill EI for that agency.

-Creating a new EI Agency-

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