Using the "back" button in your web browser or the "Cancel" button below will cause this form to start over at step 1 and you will lose all data previously entered.

Step 1 of 6

Type of Update
If you wish to only update a provider’s name, degree, and/or specialty, please email your changes to our Credentialing department instead of completing this form. Please include the effective date of the change in your e-mail.

To make an update to an address record (including primary, additional, billing, or mailing address, phone number, tax identification number, etc.) select an option below. During a later step in this form, you will be asked to list all providers and/or facilities impacted by this update. If you have updates to multiple addresses, you must complete an update form for each unique address.

Please note: If submitting electronic claims, effective January 1, 2012, a street billing address will be required in addition to a PO Box, Drawer or Lock Box used as the billing/remit to address.

 

* Required Field

Type of Update

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Add a new practice location Update an existing address Terminate an existing address Add a network provider(s) to your practice/facility