New consolidated practice and provider demographic change form

March 2024

We have a new practice and provider demographic change form that should be used to submit updated information for your practice and/or providers. 

What’s changing?

This single form has replaced the 4 separate forms that were previously needed based on the following type of change: 

• Address Relocation
• New Practice
• Practice Closure
• Provider Transfer 

Important reminders

You are required to complete the Practice location information (as it is currently listed in our system) section of the form with any change submitted.

If you have copies of the 4 separate forms saved, please delete or discard them and use only this consolidated demographic update form going forward.

Events to use the new practice and provider demographic change form

This new consolidated form can be used to submit any of the following types of updates or changes, making it easier to notify us of any changes to your practice or provider information:

• Practice location closure: One of your office locations is closing — not a full practice closure, only closure of a single office location (requires 30 days’ advance notice)
• Practice address change: Your practice office location has relocated to a new address
• Practice location name change: Your practice’s business name needs to be updated (tax name remains the same)
• Pay-to address change: The address where payments are to be sent needs to be updated
• Add new location: Your practice is adding a new office location
• Provider location change: An in-network, credentialed provider located at one office location needs to be affiliated with another or a different office location
• Provider practice transfer: An in-network, credentialed provider is transferring from one practice to a different practice

When to not use the new practice and provider demographic change form

This form should not be completed for ownership or tax-related changes to your practice. Any tax-related change requires a practice change of ownership/Tax ID change form. Please note that any tax-related change requires, at minimum, 30 days’ advance notice.

Where to find the form

Review this new form on our hearing provider resources website under Credentialing.