Indicates required field
First Name:
Last Name:
Telephone Number:
Ext:
Job Title/Position:
Email Address:
Name of Provider/Group:
Tax ID Number:
Rendering NPI:
Billing NPI Number:
Attach signed and dated W-9 for name change. If you have multiple titles please list additional titles in the below comments box.
Middle Name
Suffix: I II III IV JR SR
Current Title:
Current Practice Name:
URL:
URL N/A
Middle Name:
New Title:
New Practice Name:
Attach signed and dated W-9 with correct classification box checked.
Current Billing NPI Number:
Current Tax ID Number:
New Billing NPI Number:
New Tax ID Number:
Complete a separate form for each office physical address change request. This information is utilized for the member directories. A P.O. Box address will not be accepted as an official physical address. If your primary address change involves moving to a different county, this could impact your claims payment.
Address Line 1:
Address Line 2:
City:
State: AA AE AK AL AP AR AS AZ CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MH MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Other
Zip Code:
Email:
Fax Number:
This location is closed
Accepting New Patients: Active, Accepting New Patients Active, Accepting Newborns Only Active, Closed to New Patients Active, Open to All Members Awaiting Departicipation
For more than one set of hours for same day, please note in the comments box below.
Open 24/7
Changes requested to a group's information will only be accepted if submitted by the group. Supporting documentation must be submitted on the group letterhead.
Credentialing Contact Name:
Administrative Contact Name:
Hospital Privilege (list all):
Ambulatory Surgery Center Privileges (list all):
License Number:
Specialty:
Subspecialty:
Specialty Effective Date:
Specialty Certification Date:
Are you a physician authorized to dispense Medication-Assisted Treatment (MAT) for Opioid Use Disorders?
Is Medication Assisted Treatment for Opioid Use Disorders provided at this location?
Is counseling provided for Opioid Use Disorders at this location?
This location is a certified Opioid Treatment Program?
Would you prefer to keep the MAT answers private? You can choose to not disclose this information with our members?
Date Of Birth:
DEA Number:
DEA Number Expiration Date:
Languages (spoken or written):
Medical School Name:
Date of Graduation:
Residency Hospital Name:
Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black Hispanic White
Scheduling Telephone Number
Please select at least one if Telehealth is selected as Yes.
Please complete the required fields for Physical Address and Billing Address Information. This information is utilized for the member directories. A P.O. Box address will not be accepted as an official physical address.
If you are removing a provider from more than two service locations, please Attach an Excel file with all applicable locations.
Individual Provider Name:
Individual's Type 1 NPI:
Other ID Number (Eg: Medicaid #, API #, LTSS #, TPI #):
Remove Provider from all locations on file
Reason for leaving: Deceased Retired Left Group Individual no longer at service location
Effective Date of Termination:
Add another location for removal
I certify that the information submitted within this form is accurate and complete.