Update Practice Information
Follow the instructions below to update the individual, group practice, or facility information we have on record for you. We share this information with members in our Provider Directories.
- Accepting new patients
- Address1, telephone/fax number, ie. Primary Office, Medical Records, Billing, Correspondence, Remittance
- Facility/Ancillary Name
- Group Name
- Office hours
- Practitioner Name
- Telehealth services offered
- Terminate a group, facility or practitioner2
- Any other data changes that have occurred within your practice, displayed on the directory or not (including Tax ID updates)
1When submitting address or service location updates: Service locations must be a street level address. PO boxes are not acceptable. Home addresses, if indicated as such, supplied for telehealth services will not be listed in the directory unless requested on the form.
2Terminating a Licensed Physician: Any nurse practitioner (NP), physician assistant (PA), or certified behavior analyst assistant that has a collaborating relationship with the terminated licensed physician must complete an Application for Non-Physician Health Care Practitioner to be reassigned.
Step 1: Select the Provider Demographic Form
Step 2: Save Form to your desktop.
For Chrome: Select the download Icon.
For Firefox: Select the download Icon.
For Internet Explorer: Select the download Icon.
*Remember the form name to help find it later when you submit it to us.
Step 3: Fill out Form & Save.
Step 4: Use the Link below to upload and send form.