Provider Information Changes

Please keep your practice information in the Alliance's system up-to-date. Your updates must be made in writing on office letterhead with the Provider or Office Manager's signature, and may be submitted via mail or fax. Fax us at (877) 747-4508.

Please inform us right away about changes to your practice, such as a new address or suite number, phone, fax, tax identification number (TIN), ownership or group name change, provider additions or deletions, or any new practice limitations. Note: A W-9 form is required for any changes to a group name, new ownership, or TIN.