Practitioner or Provider Change Form 

This form should be used when changes occur such as practitioner changing name, specialty, degree / credentials or minimal clinic changes – such as a name change, address change such as adding a suite number, changing a phone or fax number or changing a billing address. For practitioners adding a new location, please use the New Practitioner Form. For location moves, please use the Location Termination Form and New Location Form.

This form should not be used in place of New PractitionerNew LocationTerm Practitioner and Term Location Notification Forms.

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