Are you a clinician changing your practice address or phone number? Instructions are available at Office Resources>Enrollment>Maintaining & Changing Status.
Behavior Analysts, please use the form for Ancillary Professionals.
Institutional providers may use this form to notify us of a change in ownership or control.
Institutional providers use this form to notify us of contractual or non-contractual changes. To add an individual clinician to your contract, please use a form for professional providers (above).