Accurate data matters!

Keeping your practice data up to date through Aetna Better Health of Florida’s online Provider Data Change Form is essential to ensuring member satisfaction, appropriate referrals, appointment availability, and accurate and timely claims processing.
 
Instructions: Please complete the Provider Data Change Form (PDCF) for each practitioner in your practice that requires changes and only fill out the fields that require changes in the system.

NOTE: This form is not for New Providers, Contractual or Credentialing updates. If you are adding a practitioner to an existing group please submit a credentialing application. 

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* Submitter Information

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* Provider Online Directory Changes Required (select all that apply).

Note: If you are adding Group Affiliations to a practitioner and the Group is not contracted please complete the Provider Nomination Form and follow the instruction on the form.

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* Group Practice Information (all  fields are required)

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* Email Address (enter email used to receive Health Plan notifications)

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* Website

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* If pay-to address has changed, please attach a W9.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* Telehealth Services Provided (Y/N)

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* Indicate if there are any changes to the Line of Business (Plan).

  Status
Florida Medicaid (MMA)
Florida Healthy Kids (FHK)
Florida Long-Term Care (LTC)

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* Practitioner Information (all fields are required)

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* Is the practitioner still practicing with the group?

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* If terminating practitioner from the practice, please attach a Termination Letter on the company letterhead. 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* Current State License Number

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* Updated State License Number

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* Current Primary Specialty (select from the dropdown)

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* Updated Primary Specialty (select from the dropdown)

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* Current Secondary Specialty (select from the dropdown)

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* Updated Secondary Specialty (select from the dropdown)

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* Current Certifying Board (select from the dropdown)

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* Updated Certifying Board (select from the dropdown)

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* Current Ages Served

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* Updated Ages Served

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* Current Gender (select from the dropdown)

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* Updated Gender (select from the dropdown)

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* Current Ethnicity/Race (select from the dropdown)

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* Updated Ethnicity/Race (select from the dropdown)

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* Current Language(s) Spoken (enter all that apply)

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* Updated Language(s) Spoken (enter all that apply)

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* Other Comments

If Provider Online Directory changes are required for Accepting New Patients, Office Hours, Handicap Accessibility, and Service Locations continue to the next page.

If Provider Online Directory changes are required for Hospital Affiliations continue to page 3.

Otherwise, continue to the last page to Submit the form. Please note that the form must be Complete and Submitted in order to be processed. Incomplete forms will not be accepted.
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