Provider Update Form Provider Update Form You must have JavaScript enabled to use this form. Provider Information Update Form In order to process the update, include any associated provider(s) and NPI(s) number(s) that we need to have listed under the change.Please submit a provider roster, W-9, or other necessary documentation below. This information is typically required to complete this request.Important: Submission Instructions for Provider DocumentationDue to security constraints, providers are currently unable to attach documentation directly to the Provider Information Update Form. Until further notice, please submit any accompanying documentation (rosters, W9 forms, etc.) via email to: provider.relations@hsc.utah.eduTo help ensure documents are received and processed efficiently: Complete and submit this form (Note: A copy of the form submission & values will be emailed upon submission) In the subject Line, please include Form Submission ID: 8f1150fc-f30b-449b-b161-dd54432fb49a, as well as, the provider or organization name. To help ensure documents are received and processed efficiently, please combine multiple files into a single ZIP or other archive file whenever possible before sending your email. Anything with a * next to it is a required field. EFFECTIVE DATE OF CHANGE * CHANGE INFORMATION ADD A NEW LOCATION TERMINATION GROUP TAX ID * GROUP NPI * CONTACT INFORMATION (IF A DIFFERENT CONTACT PERSON IS USED FOR EACH SERVICE TYPE. ATTACH INFORMATION BEFORE SUBMITTING THIS FORM.)(PICK ALL THAT APPLY) PRACTICE CONTRACTING CREDENTIALING NAME PHONE EMAIL FAX EXISTING ADDRESS Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code EXISTING PHONE EXISTING FAX EXISTING BILLING ADDRESS Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code BILLING PHONE BILLING FAX PRACTICE INFORMATION PRACTICE LOCATION NAME * * ASSOCIATED PROVIDER: (IF MULTIPLE PROVIDERS, ATTACH INFORMATION AS A SPREADSHEET OR OTHER FORM OF ROSTER BEFORE SUBMITTING THIS FORM.) ASSOCIATED PROVIDER NAME ASSOCIATED PROVIDER NPI NEW PRACTICE ADDRESS Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code PRACTICE CONTRACTING CREDENTIALING (PICK ALL THAT APPLY) LOCATION INFORMATION (PLEASE CHECK ANY THAT APPLY TO THE OFFICE LOCATION) EXTENDED HOURS PEDIATRIC SERVICES MEDICATION ASSISTED TREATMENT VIRTUAL VISITS MOBILE MEDICINE MENTAL HEALTH TREATMENT EATING DISORDERS LANGUAGE TRANSLATION SERVICES SUBSTANCE USE TREATMENT LGBTQ+ FRIENDLY ENVIRONMENT DOMESTIC VIOLENCE SUPPORT AVAILABLE VISUAL IMPAIRMENT ACCOMMODATIONS HEARING IMPAIRMENT ACCOMIDATIONS ADA COMPLIANT & HANDICAP ACCESSIBILITY ADA COMPLIANT HANDICAP ACCESSIBILITY (PLEASE CHECK ALL THAT APPLY) PARKING INTERIOR BUILDING EXTERIOR BUILDING WAITING/RECEPTION RESTROOM EXAM ROOM EXAM TABLE MAMMOGRAPHY EQUIPMENT STRETCHERS & GURNEYS LIFTS RADIOLOGIC EQUIPMENT WHEELCHAIR WEIGHT SCALE PRACTICE PHONE PRACTICE FAX PRACTICE EMAIL GENDER RESTRICTION (IF ANY): AGE RESTRICTION (IF ANY): CULTURAL COMPETENCY TRAINING DATE Website URL: By providing the URL to your clinic website, you give University of Utah Health Plans permission to publish a link to your site in our provider directories. U of U Health Plans assumes no responsibility or liability for the information displayed on your site. WEBSITE URL NEW BILLING ADDRESS Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code CONTACT NAME NEW CONTACT PHONE NEW CONTACT FAX NEW CONTACT EMAIL WHAT ELSE WOULD YOU LIKE US TO KNOW? Leave this field blank
