Keeping your practice information up to date is the best way for our members to find you in our Provider Directories, and it’s never been easier using our online Practitioner Demographic Changes form! It’s the fastest and most efficient way for us to receive and process your updated information.
Examples of the information you can update using the Practitioner Demographic Changes form.
Two Ways to Submit Updates - Online Form or PDF
Method 1: Online Form (Recommended Method)
Use our online form to update your practice information.
Practitioner Demographic Changes form (requires Login)
Method 2: Fill out PDF form and submit
Step 1: Select the Practitioner Demographic Changes form
- Remember the saved form name to help find it later when you submit it to us.
- For Chrome: Select the download Icon. (top right of page)
- For Edge: Select the download Icon. (top right of page)
Step 3: Complete the form and save your changes
Step 4: Send completed PDF form via mail, fax, email or use the link below to upload and send.
What Information Can be Updated?
- Accepting new patients
- Address, telephone/fax number, i.e., primary office, medical records, billing correspondence, remittance
- Service locations must be a street level address.
- P.O. 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.
- Facility/Ancillary Name
- Group Name
- Office hours
- Practitioner Name
- Telehealth services offered
- Terminate a group, facility or practitioner
Any nurse practitioner (NP), physician assistant (PA), certified behavior analyst assistant, licensed master social worker (LMSW), or licensed creative arts therapist (LCAT) that has a collaborating relationship with the terminated licensed physician must complete an Application for Non-Physician Health Care Practitioner to be reassigned.
- Any other data changes that have occurred within your practice, displayed on the directory or not (including Tax ID updates)