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Provider Update Request



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

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?



* 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.