Behavioral Health Provider Demographic Updates

If you are a participating provider, and would like to submit updates to your demographic information, please fill out the form below.

Please note that if you would like to add a practitioner to your Group Practice, or a Facility NPI to your organization, please fill out a Become a Provider request online instead.

Also, if you are looking to update a TIN please reach out to your Provider Relations Representative instead.

What provider type are you? Solo Practice Group Practice Facility/Agency

__________________________________________________________________________________________________________

Please download and fill out the Provider Change Form. Once you have completed filling it out and signing it, please attach it to your request below.

Provider Change Form

__________________________________________________________________________________________________________

Please download and fill out the Facility Change Form. Once you have completed filling it out and signing it, please attach it to your request below.

Facility Change Form

__________________________________________________________________________________________________________

Provider Organization Name *

Is this update for only one practitioner in your Group, or does it affect the entire Group Itself? * Just one practitioner in my Group The entire Group Practice

Provider First Name *

Provider Last Name *

TIN * Please no dashes "-"

Organization NPI *

Individual NPI *

Credentialing Contact Name *

Credentialing Contact Phone *

Credentialing Contact Email *

Provider/Facility Change Form *

W-9 - required for any changes to the 1099 billing address

Supporting Document