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Provider Update Form

** IMPORTANT ** You must submit a W9 and sample CMS 1500 form for each location change or addition.

Submitter Information

Provider Identification

Provider Name Change

Items required for name change: License, DEA, CSR, Certificate of Insurance (COI), Collaborative Practice Agreement (CPA), 1500 claim form (blinded/voided), Legal Document supporting name change (marriage license, court document, etc.) driver’s license

Terminating a Provider

Adding a Practice Location

Items required to add location Certificate of Insurance (new TINs), W9, 1500 claim form (blinded/voided), Collaborative Practice Agreement (CPA) if applicable
Is this the primary location for provider?:
List location in provider directory? (Only locations where patients are routinely seen should be listed in directory.):
If adding a practice location, you must complete the "Add A Pay To/Remit To Location".

Add a Pay to/Remit to Location

Eliminate Practice Location

Change Practice Location

Change Pay to/Remit to Location

Additional Information

A single document can be attached to this request. You can combine all of the documents required into a single pdf file or create a zip file. If you do not wish to attach, the documents can be faxed to 812-450-2030.
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