To make sure you receive referrals, claims payment, credentialing, and other important documentation in a timely manner, we need you to notify us when information about you or your practice changes.
This page includes forms you may need from time to time to notify Magellan about changes in your practice. These forms require you to have Adobe Acrobat Reader software to open and may be printed and photocopied as needed. In lieu of these forms, you may submit much of this information online through web-based applications after signing in to this website.
Practice Information Form (PDF 84K)
This form is used to identify specific populations, specific issues, or specific services/procedures that you offer in your practice. This information is used to make the most appropriate member referrals based upon provider specialties, interest, and experience.
Provider Data Change Form (PDF 200K)
The Provider Data Change Form is used when you want to update the practice information in your Magellan provider file. Information that can be updated using this form include: billing, mailing, service and home addresses, phone and fax numbers, business hours of operation, Taxpayer Identification Number, and license information.
W-9 (PDF 36K)
If you change your billing Taxpayer Identification Number (TIN), you must complete and submit a Form W-9 listing the legal name of the payee and the type of TIN – Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer Identification Number (ITIN). Return it to Magellan Health Services, Inc; Attn: Data Management; 14100 Magellan Plaza; Maryland Heights, MO 63043 or fax to 888-656-3804.
California providers must complete this form to meet regulatory requirements of the California Department of Managed Health Care. You may complete it electronically. If you have questions, contact our California Network team at 1-800-430-0535, option #4, or at CaliforniaProvider@MagellanHealth.com.
1099 Contact Information
For inquiries regarding your Form 1099, please contact Nancy Innes at 1-800-450-7281, ext. 75001.
Adobe Reader is required to view PDF files.