Contents
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Edit Provider Profile
To edit any of the displayed information for a provider profile, click on the Edit Profile button at the bottom of the page. As a result, the Edit Provider Profile page (LI0005) is presented.
On this page, you may edit any of the information previously recorded for the provider.
Initial Application Date
The initial application date may be changed if appropriate. This would most likely be done if there were a typographical error upon the entry of the original application.
Center Name or Last*, First and Middle Names and Suffix
Enter the name of the provider in the appropriate name fields.
Facility Street Address*
Enter the first line of the Location Address in this field.
Facility Street Address Line 2
Enter the second line of the Location Address in this field.
City
Type the name of the city for the location in this field.
Town
Select the name of the town for the location by using the down arrow (
) next to the field.
State*
The State has been defaulted to Vermont; however if another selection is needed, select the name of the state for the location by using the down arrow () next to the field.
Zip Code*
Enter the zip code for the location in this field using the format #####-####.
Postal Address (If different from location address)
Enter the first line of the Mailing Address in this field.
Postal Address Line 2
Enter the second line of the Mailing Address in this field.
City
Type the name of the city for the Mailing Address in this field.
Town
Select the name of the town for the Mailing Address by using the down arrow () next to the field.
State
The State has been defaulted to Vermont; however if another selection is needed, select the name of the state for the Mailing Address by using the down arrow () next to the field.
Zip Code
Enter the zip code for the Mailing Address in this field using the format #####-####.
EIN
Enter the Employer Identification Number for the applicant as appropriate.
SSN
Enter the Social Security Number for the applicant as appropriate.
Contact Phone Number*
Enter the contact telephone number for contact in this field using the format ###-###-####.
Web Site Address
Enter the URL for the provider's web site.
Electronic Participation*
Select either Yes or No for the selection by using the radio button next to the field (
). If this answer is Yes, the following two fields are required if provider elects to participate electronically.
Participation Request Date
Enter the date on which electronic participation is requested.
E-mail Address
Enter the complete e-mail address for the provider.
More:
Save Updates to the Provider Profile
Cancel Updates to the Provider Profile