Provider Demographic Change Request
Rendering Provider Name
Rendering Provider NPI
Group with Practitioner(s)
Group Billing NPI
Service Address Effective Date: _____________________
Remit Address/W-9 Effective Date: _____________________
Phone or Fax
Other (please explain)
Current Service Address
Current Remit Address
New Service Address
New Remit Address
Tax ID Number (Include W-9)
Forward completed form along with a W-9 to Provider Data Management Services via fax
at 714-954-2330 or email to firstname.lastname@example.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.
ider Data Management Services