SUBMITTER DETAILS
Date Today (MM/DD/YYYY) *
Practice Type *
Practice Tax ID Number (TIN) *
Practice National Provider ID (NPI) Number *
Practice Name *
Provider Name *
Submitter Name *
Submitter Email Address *
Submitter Title
Submitter Phone *
Submitter Phone Extension
NPI DETAILS
Atypical Provider?
Atypical Provider Explanation
NPI Taxonomy Code
NPI Issue Date (MM/DD/YYYY)
Basis for NPI Number (Refer to NPI Table)
NPI Level of Information (Refer to NPI Table)
ADDRESS DETAILS
Address Type
Do you want correspondence at this address?
Federally Qualified Health Center (FQHC)?
Is this the primary practice location?
New Address Effective Date (MM/DD/YYYY)
Please choose to let us know what you'd like to update:
Add Change Delete
If you would like to update more than one address, please submit both practice address change request pages for each additional location.
UnitedHealthcare | Practice Address Change Request
OLD Address
Street Address 1 *
Street Address 2
City *
State/Territory *
Zip Code
*
Country *
NEW Address
Street Address 1
S
treet Address 2
City
State/Territory
Zip Code
Country
Practice Location Phone/Fax Number
Old Phone Number
Extension
New Phone Number Extension
Old Fax Number Extension
New Fax Number Extension
Practice Website
Old Practice Website
New Practice Website
Practice Email
Website/Email Instructions:
1)
Add Website/Email: Enter NEW Website and/or Email ONLY
2)
Change Website/Email: Enter Both OLD and NEW Websites and/or Emails
3)
Term Website/Email: Enter OLD Website and/or Email ONLY
Old Practice Email
New Practice Email
List Website in UHC Directory?
LOCATION DETAILS
Telehealth Service Capability?
Accepting UHC Members?
Accepting VA (Department of Veterans Affairs)?
Accepting Civilian Health & Medical Program of Veterans Affairs
(CHAMPVA)? Accepting Medicaid Members?
Accepting Medicare Members?
List Email in UHC Directory?
Address Instructions: Enter OLD Phone and/or Fax Number ONLY and:
1)
Add Address: Enter NEW Address ONLY
2)
Change Address: Enter Both OLD and NEW Address
3)
Delete Address: Enter OLD Address ONLY
Phone/Fax Instructions: Enter OLD Address ONLY and:
1)
Add Phone/Fax: Enter NEW Phone/Fax ONLY
2)
Change Phone/Fax: Enter Both OLD and NEW Phone and/or Fax
3)
Delete
Phone/Fax: Enter OLD Phone/Fax ONLY
N/A
N/A
N/A
N/A
Provider Demographic Change Request Form
Version 1.0 | Last Modified: October 2020
List Address in UHC Directory? *
If No, Select Reason
If Care Provider Has CA-Specific Exemption, Select Reason
please attach a signed statement
The care provider fears for their safety or their family’s safety because of their affiliation with a health
care service facility or because they provide health care services.
This location, facility or any of its care providers, employees, volunteers or patients is or was the
target of threats or acts of violence within the past year.
The care provider is currently enrolled in the state’s
Safe at Home program.
