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Behavioral Health Provider Demographic Updates

If you are a participating provider, and would like to submit updates to your demographic information, please fill out the form below. 

Please note that if you would like to add a practitioner to your Group Practice, or a Facility NPI to your organization, please fill out a Become a Provider request online instead.

Also, if you are looking to update a TIN please reach out to your Provider Relations Representative instead. 

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Please download and fill out the Provider Change Form. Once you have completed filling it out and signing it, please attach it to your request below. 

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Please download and fill out the Facility Change Form. Once you have completed filling it out and signing it, please attach it to your request below.

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