Provider Updates

Need to update your provider information?

Participating in-network providers can update their contact information, NPI number, and Tax Identification Number (TIN) below.

Step one:

Complete the online form below.

Step two:

Submit additional documents, as required, (e.g., W9, licensure) using one of these methods:

  1. Upload documents to this online form when submitting.
  2. Send documents separately via email or secure fax. Print this cover page for all documents submitted via email or secure fax.


Secure Fax : 214-390-2139

Please allow ten (10) business days for your changes to update in our system.

If you have questions, please call the Provider Support Team at 888.806.3400

*indicates required field

Please complete this form if you are submitting these changes on behalf of a provider.

Phone Changes

 Edit correct current phone
 Add new phone number
 Remove existing phone number

Other changes (corporate or personal)

 Name Change: (W9 form required)

Address Changes

 Physical office address (cannot be a P.O. Box)
 Mailing address

 Edit current adress
 Add new adress
 Remove existing adress

 Tax ID Number change: (W9 form required)

 NPI Change