Provider Information Update Form
Questions? Call Provider Relations at 1-888-895-4998
Notification must be made at least thirty (30) days in advance of the change in writing or using this form.
Complete this form with all current information.
PLEASE NOTE: IF USING A SOCIAL SECURITY # IN PLACE OF A TAX ID, THIS COMPLETED UPDATE FORM MUST BE FAXED TO 410-762-5302 TO ENSURE IDENTITY PROTECTION.