Provider Demographic Change Request Form

Provider Demographic Change Request Form
Please be advised that updating your demographic information does not change the mailing address for future claim payments. In addition to this form, and to ensure payments are sent to the correct location, please verify and update the billing address on your claim submissions accordingly.

If you are missing any payments, please contact our Customer Service Department at the phone number on the back of the member's ID card.
Requester Information
Name*

First NameLast Name
Position*
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Provider/Practice Information
Provider Change Information (this change affects...)*

Group PracticeSole ProprietorInstitution/Facility
Provider Type*

MedicalMental HealthDentalPharmacy
Provider/Practice Name*
TIN*
9 Digit Tax ID Number
Group NPI*
Group National Provider Identification Number
Rendering NPI Number is the same as Group NPI Number

YesNo
Rendering NPI*
Rendering National Provider Identification Number
Effective Date of Change*

MonthDayYear
Date
Type of Change (Select all that apply)*

Address Change - Billing AddressAddress Change - Practice/Facility LocationSubmit/Update W9
Submission of a W9 alone will not update billing/mailing addresses, the W9 form is intended for tax purposes only.
Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attention: Claim submission is not permitted on this form, any claim forms uploaded will be deleted.
Supporting Documents if Applicable

Cancelof
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Should be Empty:

Provider Demographic Change Request Form

Requester Information

Provider/Practice Information