Mental health and chemical dependency professional
contact form
Please note: This
form is to be used by behavioral health
and chemical dependency professionals
contact their provider services representative.
Please complete a Provider Information Update Form when:
- A provider leaves or joins your clinic or practice
- You have a change to your:
- Organization's address
- Phone number
- Tax identification number
- National Provider Identifier number
The results of this form are encrypted and
sent to our secure server for your privacy.
Your form will be sent directly to your allied
services representative. Please allow up to
five business days for a response. For a more
immediate response, please phone
your allied services representative directly.
*Asterisks indicate required fields.
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