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 855.891.7257.

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.