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Changes & Additions

The following are options for CBO Enrollment changes and additions:


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. To do this click on the name change link below and download/complete the EI Service Matrix Form and W-9 Form using the instructions that come with the documents. 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 use the EI Service Matrix and W-9 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 use the EI Service Matrix Form and W-9 form contained in the link below. Provider agencies must also 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 using the forms contained in the link below. Only providers who are currently enrolled should use these forms for enrolling independently. 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 using the forms 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 should use the forms 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 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-

Adding a New Service Provider Type

EI providers who are currently enrolled in the EI Central Billing office to provide one type of EI service and would like to add a new Provider Type, must apply for the desired credential and submit the documents contained in the link below. For example a ST, OT, or PT wanting to be eligible to bill for DT services must complete these documents.

-Add new Provider Type-

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