Request Leave of Absence or Closed to New Patients Status
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to request a Leave of Absence or Closed to New Patients Status.
Leave of Absence: This means that your Heraya network status will be temporarily put on hold. Leave of absence can be requested for the following reasons: medical leave, travel, vacation, and/or to request a locum tenens provider to treat Heraya members in your absence. Your name will be removed from Heraya's provider directory until you are reinstated to a regular active status.
Closed to New Patients Status: This means that your Heraya network status will remain active, but you now have the option to only accept established Heraya members and not accept new Heraya members for a period of up to six (6) months. You still have the option to accept new members at your discretion. Your name will be removed from Heraya’s provider directory until you are reinstated to a regular active status.
Please note: Please submit LOA and call coverage requests at least 10 business day prior to the effective date to ensure CHP has adequate time to process your requests.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Update My W-9 Form
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
Please fax a new W-9 form to CHP Provider Services Department at 877-482-2856, noting the applicable location on the form. The IRS has a fillable pdf W-9 form online
here.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing, at which time you may start billing with your new tax ID.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Add a Secondary Practice Location
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to add an additional practice location with no changes to your currently credentialed practice location(s).
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing, at which time you may start treating patients at your secondary location. If your secondary practice location is not yet effective, please provide the date you will begin practicing there.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Remove an Office Location
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to remove a practice location with no changes to your additional credentialed practice location(s).
Please note: This request is only applicable if you have more than one location credentialed with Heraya. If you are only credentialed at one location, please return to the Provider Information Update Form page (previous page) and request “Leave of Absence (LOA)” or “Resign from Heraya Health Network”.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.Change My Billing Address
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to update the address where you receive payments. This request is separate from your mailing address. If you would also like to update your mailing address, after completing this form, please return to the Provider Information Update Form page and request “Change my mailing address”.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Change My Mailing Address
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to update the address where you receive mail. This request is separate from your billing address. If you would also like to update your billing address, after completing this form please return to the Provider Information Update Form page and request “Change my billing address”.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Update My Phone, Fax or Email
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST
This form will guide you through providing the information to update your contact information.
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.Change My Name
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing the information to update your first or last name as it appears on our website and documents provided to you by Heraya.
Please note: If you bill Heraya with your Social Security Number (SSN) as your tax ID, please fax a new W-9 form to the Heraya Provider Services Department at 877-482-2856, noting the applicable location on the form. The IRS has a fillable pdf W-9 form online
here
Effective date: Effective dates are determined by the date we receive the completed information. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
Resign from Heraya Health Provider Network
PLEASE REVIEW THIS INFORMATION BEFORE COMPLETING YOUR REQUEST.
This form will guide you through providing information necessary to request removal from the Heraya network and no longer treat Heraya members.
Please note: If you have active Heraya members within the past 90 days, your contract requires you to remain on network for an additional 60 days from the date of your resignation request to provide continuity of care.
Effective date: Effective dates are determined by the date we receive the completed information, and if you have active members under your care. You will be notified of your effective date in writing.
If you have not received a response to this submission within 10 business days, please contact the Heraya Provider Services Department at ps@herayahealth.com or 800-449-9479 to ensure receipt.
