Provider Update Form Provider Update Form You must have JavaScript enabled to use this form. Provider Information Update Form Please include any associated provider(s) and NPI(s) number(s) that we need to have listed under the change. If needed, attach a provider roster, W-9, or other necessary documentation below. This information is required to complete this request.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 (PICK ALL THAT APPLY) PRACTICE CONTRACTING CREDENTIALING LOCATION INFORMATION (PLEASE CHECK ANY THAT APPLY TO THE OFFICE LOCATION) EXTENDED HOURS PEDIATRIC SERVICES HANDICAP ACCESSIBLE VIRTUAL VISITS MOBILE MEDICINE MENTAL HEALTH TREATMENT EATING DISORDERS LANGUAGE TRANSLATION SERVICES VISUAL IMPAIRMENT ACCOMMODATIONS DOMESTIC VIOLENCE SUPPORT AVAILABLE SUBSTANCE USE TREATMENT LGBTQ-FRIENDLY ENVIRONMENT 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? ATTACH ADDITIONAL DOCUMENTATION Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx, xml, zip. Leave this field blank
