Provider Information Update Form

Form Instructions

Use this form to notify us about changes in your practice.

Please contact your Provider experience representative if your request is due to:

  • A change in where your payments are directed, or
  • If you are closing a practice, or
  • If you are terminating a network affiliation for any reason, or
  • If you are an organization and have changed ownership

Fields marked with an asterisk (*) are required fields.

Please help us identify the change type request:*
This is new information, not a change    
   
Changes apply to:*
   
   

Your details

Please enter your contact information for this change request:

Last name:*  
First name:*  
Organization name(s):  
Email:*  
Phone:*  
Effective date of change:* [mm/dd/yyyy]  

Behavioral health providers: Please use the Behavioral Health Practitioner Areas of Clinical Focus Form to update your areas of clinical focus or modalities.

Who is this change for?

  • Please complete both the Old and New Information sections if you are submitting updates to existing providers.
  • If you are adding a new provider to your practice, please complete only the New Information fields below.
Old IDs   New IDs  
Provider Last name: Provider Last name:
Provider Middle name: Provider Middle name:
Provider First name: Provider First name:
Organization name(s): Organization name(s):
Doing business as (DBA): Doing business as (DBA):
Provider NPI: Provider NPI:
Organization or clinic NPI: Organization or clinic NPI:
Old Tax ID: New Tax ID:
Medicare billing number: Medicare billing number:

Do you offer telehealth to the general public or current patients?*
Offers to general public    
Offers to current patients only    
Does not offer at all    
 

Physical address

Old physical address   New physical address  
Street address 1: Street address 1:
Street address 2: Street address 2:
Suite: Suite:
City: City:
State: State:
Zip: Zip:
Handicap access: Yes No Handicap access: Yes No
Phone: Phone:
Fax: Fax:
Email: Email:

Billing address

Billing address same as physical address above. Yes if checked; No if not checked
Billing phone number same as physical phone number above. Yes if checked; No if not checked
Old billing address   New billing address  
Billing address 1: Billing address 1:
Billing address 2: Billing address 2:
Suite: Suite:
City: City:
State: State:
Zip: Zip:
Phone: Phone:
Fax: Fax:
Email: Email:
An Asuris representative may contact you by phone to verify billing address changes.

Practice information

Accepting new patients?* Yes No    
Practice primary care?* Yes No    
Print in directory?* Yes No    
Interpreter services?* Yes No    
Specialty: (List all that apply)  
Degree(s): (List all that apply)  
Other languages: (List all that apply)  
Taxonomy code:    
Provider data validation:      

Practice Data Validation E-mail:*

   

eContracting account

Are you currently signed up for electronic contracting? Yes No  
If no, provide us with the following information on the person responsible for signing contracting documents:
  First name: Last name:
  Email: Phone:

Please provide any additional information to assist us locating the appropriate provider record, or information that you require be updated:

Please contact your Provider experience representative for any questions about this form or updates to your information.