Provider Information Update Form

Use this form to notify us about changes in your practice. Fields marked with an asterisk (*) are required fields.

Dental providers

Visit asurisdental.com to submit changes to your practice information. Do not submit this form.

Network termination or closing a practice

If you are terminating a network affiliation or closing a practice, do not submit this form.

  • Refer to your provider agreement and our Contact Us page for instructions and address for submitting a network termination notice.
  • Exception: Removing one provider from a group contract only can be requested by submitting this form.

Your details

Please enter your contact information for this change request:
       
First name:* Last name:*
Phone:* Email:*
Organization name(s): Effective date of change:*
Tax ID:*    
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?
Type of change request:*   Change applies to:*  
This is new information, not a change The provider only  
This is a change to your existing information The entire organization  
       
  • 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.

Electronic contracting

All provider agreement notifications are made by email. Contractual documents must be reviewed and signed electronically by the person delegated (the legal contract signatory) to receive contractual notifications and sign provider agreements on behalf of contracted physicians or other health care professionals at your practice.

Legal contract signatory email:    

We recommend you use an email account dedicated to contracting that remains with the provider instead of an individual's email account. This will ensure future contractual communications are received regardless of staffing changes.

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:
Medicare billing number: Medicare billing number:
Old tax ID: New tax ID: (see Notes below)

Notes:

  • If you are making changes to your practice location or tax ID, we require a signed copy of your 147C or CP575 letter. Please fax these documents to 1 (888) 289-1313 after submitting this online form.
  • If changing your tax ID, you must re-register with Availity Essentials and re-enroll in electronic funds transfer. We also recommend you send your new tax ID to us 30 days in advance. We can then issue a new agreement before the start date of your new tax ID to avoid a lapse in your participating provider status. If we are not notified in advance, you may be considered an out-of-network provider for the dates between when your original agreement is terminated and your new agreement associated with your new tax ID is issued.

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

    
Practice website URL:    
       
Accepting new patients?* Yes No Practice primary care?* Yes No
       
Telehealth services?* Yes No Interpreter services?* Yes No
       
Print in directory?* Yes No Evening hours/weekend?* Yes if checked
       
Do you accept urgent referrals?*

Immediately (within three hours)

Within 24 hours

Within 48 hours

Within 3 days

Within 7 days

  
       
Cultural health practices?*  
  • In addition to interpreter services, all patient communications are offered in languages commonly used by the populations in our service area.*
Yes No
  • In addition to ADA accessibility, additional services are offered to patients with functional limitations (such as extended visit times, care giver coordination, scheduling flexibility). *
Yes No
  • We ensure cultural competency (language, beliefs, social structures) in the delivery of person-centered care.*
Yes No
       
Are you a Hospital and Free-Standing Facility Based Practitioner (HBFB) at this location?* If yes, we require a signed copy of your HBFB application. Please fax to 1 (888) 289-1313 after submitting this online form. Yes No  
     
Specialize in lesbian, gay, bisexual, transgender (LGBTQ+) care?* LGBTQ+ Prefer not to disclose  
       
Specialty: (List all that apply)  
Degree(s): (List all that apply)  
Other languages: (List all that apply)  
Provider race or ethnicity: Gender Preferred pronouns:  
American Indian or Alaska Native
Hispanic or Latino
Agender
Female
Gender neutral
Non-binary
Pangender
 
Other, please specify:            

Provider data validation:

    
Who should we email to validate information about your practice for our provider directory?*    

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

We process updates within 10 business days and you will NOT receive a notification it has been completed.

If you have questions after 10 days, please contact the Provider Contact Center.

Please DO NOT submit another request.