Forms make practice changes easy

Practice information helps us direct referrals and members who access care directly. It’s key in delivering timely access to care. You play a big role in keeping our provider directories up-to-date.

 

Is your practice information (e.g. practice address, areas of expertise, etc.) accurate? Prevent member servicing delays and notify us of any practice changes promptly. The Practice Update Form and the Practice Profile are convenient online options for updating your practice information.

 

Use the Practice Update Form to change the following information:

 

• Email address
• Phone and fax number
• Check/EOB/billing/ reimbursement address
• Open /closed practice status
• Mailing/correspondence address
• Tax ID (include a W-9 form with your change)
• Practice/service address

 

Use the Practice Profile when updating:

• Self-reported areas of expertise
• Open/closed practice status
• Psychiatrists update ECT, TMS, Suboxone, and anti-psychotic injectable management if applicable.
• Age ranges treated
• Additional languages spoken
• Provider ethnicity (optional)