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NOTICE: Non-network providers
Do not use the network provider forms to add a location or change your practice information. Please call the claims administrator directly at 800-323-4314. TTY users call 711. The forms are for network providers only.

Change Form
The Change Form is required when changing a service address, mailing address or contact information. You must include the previous address and an effective date of the change. The entire form must be completed as failure to do so could result in non-network payments.

Additional Location Form
The Additional Location Form is required when adding another office location under the same tax ID number.

Last Modified on Jan 21, 2022
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