For Healthcare Providers:

Demographic Update Form

NOTE: Please do not use this form to request or add a new provider or facility for participation in our network. You must complete a Request an Application form to begin the process for new participation.

Type of Update

Name, degree or specialty change

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, as well as your NPI and/or TIN in your email.

Address update/change

To make an update to an address record, please click on 'Next' below and select the type of update you wish to make. You will be asked later 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.

PO BOX NOTE: If submitting electronic claims, a physical street address will be required for the billing address. A PO Box, Drawer or Lock Box may only be used as the remit to address.

General Inquiry

If you have a general inquiry, please email our Customer Service department.