The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

6KJpSUbvQSD2i6GN6nADgNMsqg6aFoKcPcowA2DgchPH5bqvxVYzXIPDa5BgFW

ASHA/DCHA - Add/Term/Change Form

This form is for contracted practices to notify ASHA/DCHA of any new information or changes to their practice. I will verify and process the information submitted in our internal database within 2 business days. After submitting the form you will be prompted to enter your e-mail address for date & time-stamped confirmation. Your confirmation will include a PDF copy of your submission for your records.

In order to participate in the ACO all providers must be credentialed Ascension Seton Medical Staff Affairs and or Seton Physician Hospital Network depending on the provider's specialty. If I am unable to verify credentialing at the time your request comes through you will be notified via email. All uncredentialed providers will be placed on a "pending add" list that is checked for credentialed on a monthly basis.

*Please note: ASHA/DCHA does not pay claims*

ASHA/DCHA is contracted with Payors (Aetna, BCBS and SmartHealth).

Your Practice is still responsible for submitting updates/changes directly to the Payors listed above.

If you have questions please contact:

shaphysicianengagement@seton.org

Name of Submitter:

* must provide value

Title:

* must provide value

E-mail:

* must provide value

Phone Number:

* must provide value

Please specify if the information you are providing is a change is at the Practice or individual Provider level:

***IF YOU ARE ADDING A NEW PROVIDER YOU MUST SELECT "INDIVIDUAL PROVIDER" TO ENSURE YOU ARE ASKED THE APPROPRIATE QUESTIONS TO PROCESS YOUR REQUEST. IF YOU SELECT "PRACTICE/FACILITY" FOR A PROVIDER ADD YOU WILL BE EMAILED AND ASKED TO RESUBMIT ANOTHER FORM***

* must provide value

Practice/Facility (applies to all Providers/Facility)

Individual Provider (applies to a specific Provider)

reset

Is this a change to existing information on file or if it is new information:

* must provide value

Changed Information

New Information

reset

Effective date of change/update:
(Add or termination date)

* must provide value

M-D-Y

Type of Update / Change:

* must provide value

Name (Practice / Provider)

Billing Address

Office Physical Address

Office Phone / Fax

New Provider (Add) - "Individual Provider" update must be checked above

Provider Termination (Left group / Retired)

Degree/Specialty

Additional Practice Address

Practice Closing (Terminate Contract)

Other

Please specify Changes:

* must provide value

Expand

If your Practice's Tax ID Number, Legal Name and/or Billing and/or Physical Address is changing please upload W9:

* must provide value

Upload file

All Practice closures (TIN change) require an official notice be uploaded:

* must provide value

Upload file

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