Practitioner information change

Make sure your contact information is current with us. If you want to make changes to your information, all you have to do is fill out the form on page 2. It’s easy!

Make a change request today
You can fill out one form per provider in your practice. You can make changes to your:
  • Name
  • Physical and mailing addresses
  • TIN
  • NPI
  • Specialty type
  • Board certification
  • License
  • Hospital affiliations
  • Service Location Additions
  • Practitioner Resignation/Retirement (Term Date)

You’ll also want to attach important information with your change request, like a W-9 or your licensure.

Remember to complete the whole form.If you have more than ten providers that require changes, use our provider roster update spreadsheet instead. Send the updated spreadsheet to

Your information is important
Your information helps us:
  • Send payment to you without delay or error
  • Make updates in a timely manner
  • Send important information about new products and initiatives
  • Meet state and NCQA requirements

We’ll take care of the rest
Once we receive your change request, we’ll process and complete it within 30 business days. [SP1]  Remember, we can only process requests for in-network providers with a signed, executed agreement on file. So, if you’re an out-of-network provider and want to join our network, fill out our Out of Network Request to Join Form . For more questions about enrollment, contact Provider Relations at 1-866-638-1232.

Select the below sections to make changes in the respective fields
ProviderName Change    Practicing Specialties Change    Facility NPI Change    Hospital Facilities Change    Practitioner Resignation/Retirement Change    Primary Service Location/ Address Change    

Provider Type :       Individual       Group
Provider Info: Last Name * First Name * MI Degree *
Please enter last name
Please enter first name
Please enter degree
Gender DOB Group Name*
Male  Female
Please enter DOB
Please enter Group Name
Group NPI * Group TaxID *
Please enter Group NPI
Please enter Group TaxID
NPI * Medicaid ID/PROMISe * DBA Name *
Please enter valid NPI
Please enter Medicaid ID
Please enter DBA Name
Practicing Specialties Primary: *
Please enter Primary speciality.
Primary Taxonomy Code: *
Please enter Primary taxonomy code.
Secondary Taxonomy Code:
Board Certified       Yes       No Board Certified       Yes      No
If not Board Certified, are actively pursuing Board Certification:      Yes      No
Maximum number of new members accepted:
Please enter number of maximum members
Gender Restriction
DEA #: Exp. Date:
Do you have age limits for practice?
Yes No  
Please choose an option
If Yes, what are the limits?
State License#:
Please enter license ID
Date First Issued:
Please enter expiry date
State Of issue:
Please enter state of issue
NPI: TaxID: *
Please enter TaxID
NPI : number*
Please enter NPI
Hospital/Free Standing Surgery Facilities
     Active      Courtesy        Delivery        Provisional
Please choose an option

Practitioner Resignation/Retirement (Term Date) Practitioner Resignation/Retirement (Term Date): *
Please select txtResignationDate
Primary Service Location
(Main location where
provider offers services)
Primary Service Location Name: *
Please enter location name
PROMISE ID : SiteCode : *
Please enter Site Code
Effective date of Change
Please enter effective date of Change
Please enter street name
Please enter city
Please enter state
Please enter Zipcode
Please enter valid phone number
Please enter Fax number
Toll Free Phone:
Email Address:*
Please enter valid email
Handicap Accessible : *
Yes  No
Please choose an option
Office Hours:(list)*
Please enter office hours
Experience treating:     AIDS/HIV     Mental Illness     ESRD     Co-occurring disorders     Visual Impairment Evening hours:*
Yes  No
Please choose an option
Weekend hours:*
Yes  No
Please choose an option
Accommodate special needs patients: Developmentally Disabled *
Yes  No
Please choose an option
Physically Disabled *
Yes  No
Please choose an option
Services offered to the deaf / hearing impaired (circle): *
sign language TTD/TTY None available
Please choose an option
Adjustable exam table:*
Yes  No
Please choose an option
Is Office Located on public transportation route (bus/rail/ferry): *
Yes  No
Please choose an option
    Bus     Rail     Ferry/Boat
Language Interpreters: *
Please enter language
Mailing Street: *
Please enter Street
Mailing Suite:
Mailing City: *
Please enter City
Mailing State: *
Please enter State
Mailing ZIP: *
Please enter ZipCode
Mailing Phone: *
Please enter Phone
Mailing Fax: *
Please enter Fax
Provider Information
FirstName : LastName : Gender : DOB :
Primary Speciality: Board Certified : Age Limits :
NPI and other Details
Facility NPI: Facility TaxID : Medicaid ID :
Primary Taxonomy: DEA #: State License : IssuedState :
Primary Service Location Information
Location: PromiseID: SiteCode :
Street: City : State: Zip :
County: Email: Phone : Fax :
Handicap: Weekendhours: EveningHours : DisabledAccommodation :
Disabled?: Services Offered: Transportation : LanguageInterpreters :