Provider Forms & Resources
Provider Change Forms
Group Practice or Solo/Individual/Independent Provider Demographic Change Forms
To make changes to an address, NPI, tax identification number, or a group name, complete the following:
- Online Group Enrollment Change Form
- Solo/Individual/Independent Provider Enrollment Change Form
- You will need to include your current IRS Form SS-4 notice (provides verification of EIN) if you are changing your tax identification number or group name
To make a change to a provider name, complete the following:
- If the provider is part of a group practice, complete an Provider Enrollment/Change Form and include a copy of the updated State licensure and any applicable board certificates
- If the provider is an independent provider (private practice), complete an Solo/Individual/Independent Provider Enrollment Change Form and include a copy of the updated State licensure and any applicable board certificates
Mental health and substance abuse clinicians need to complete the Area of Expertise form to identify their area of expertise for marketing in the Blue national directories.
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