Update your status

If you are a credentialed provider, you may use the forms below to submit changes about your practice. Additional instructions are included on each change form. If you are making changes to your practice location, EIN, or TIN, please provide a signed copy of your IRS for 147c or CP575 letter along with the change form.

We’ll notify you in writing when your request is processed. Please allow 7-10 business days for processing. 

For non-credentialed providers, please complete the new credentialing paperwork under Join Our Network.

The Consolidated Appropriations Act (2021) and our Provider Directory Attestation Requirements for Providers policy require that directory information be reviewed and verified every 90 days.

A happy, senior polynesian woman enjoying the outdoors with her dog. A multiracial gay couple having a wonderful afternoon stroll on the beach. A happy young black couple.he upper right is an active, ethnic, senior woman of Asian and Pacific Islander descent, enjoying the outdoors with her pet dog.  The bottom is happy young, black couple taking selfies in the city while on a date.

Add a new provider to an existing contract

Open form

Add a new practice or new location

Open form

Add a network to an existing contract

Open form

Change of address or location

Open form

Change EIN or TIN

Open form

Change of specialty

Open form
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Contact us if you have questions or need assistance with changes to your practice information.

Contact Us