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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

Terminating a Provider

Did provider move out of area?:
Did provider retire?:

Adding a Practice Location

Send Correspondence to this address?:
Is this the primary location for provider?:
List location in provider directory?:
* Must complete the "Add A Pay To/Remit To Location".

Add a Pay to/Remit to Location

Send Correspondence to this address?:

Eliminate Practice Location

Change Practice Location

Change Pay to/Remit to Location

Addition or Change in Misc. Provider Information

List this specialty in the directory:
List this specialty in the directory:
Provider Role:

Addition or Change in Hospital Privileges

Accepting New Patients:

Additional Information

ATTACH FILE
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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