Provider Demographic Change Request
Rendering Provider Name
Rendering Provider NPI
Provider Type
Provider
Group with Practitioner(s)
Facility
Group Name
(if applicable)
Group Billing NPI
(if applicable)
Change Request
Service Address Effective Date: _____________________
Remit Address/W-9 Effective Date: _____________________
Phone or Fax
Other (please explain)
Current Service Address
City/State/ZIP
Current Remit Address
City/State/ZIP
Current Phone
New Service Address
City/State/ZIP
New Remit Address
City/State/ZIP
New Phone
Tax ID Number (Include W-9)
Contact Person
Name:
Phone:
Email:
Forward completed form along with a W-9 to Provider Data Management Services via fax
at 714-954-2330 or email to provideronline@caloptima.org.
All completed requests received will be processed within seven business days.
If you have any questions, contact Provider Data Management Services at 714-246-8468. All calls will
be returned within one business day.
If approved for COVID-19 Emergency Medi-Cal Provider Enrollment, please include the Department of
Health Care Services (DHCS) approval letter.
Thank you,
Prov
ider Data Management Services
