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Demographic Updates Form

– If you are a current Health Partners provider in Georgia and need to make changes to your profile, please complete the form below. If you have any questions or would like to know more about the update process, please contact the provider relations representative at 770-219-9784.

Date:

Contact Name *

First

Last

Please list providers affected by change *

Contact Phone Number *

Tax ID Number *

Please do not include dashes

Email *

Effective Date *

Accepting new patients? *

Yes
No

What changes would you like to submit? *

ADDRESS
PERSONAL ADDRESS
PHONE/FAX
CONTACT EMAIL
PROVIDER EMAIL
LANGUAGES
HOURS
PERSONNEL
ID NUMBER/TIN/ETC
AGES of patients seen
Web Site URL
PRACTICE Name
GROUP Name
Other

Change Address

Primary Location
Additional Location
Billing Address
Personal Address

Change Primary Address to

Address Line 1

Address Line 2

City

State

Zip Code

Change or add Additional Address

Address Line 1

Address Line 2

City

State

Zip Code

New Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Personal Address Change to

Address Line 1

Address Line 2

City

State

Zip Code

Change for Phone or Fax Number

Primary Phone
Additional Location Phone
Billing Phone
Primary Fax
Additional Location Fax
Billing Fax

New Primary Phone Number

New Primary Fax

Additional Location Phone

Which location?

Additional location Fax

Which Additional location?

Billing Phone

Billing Fax

Website / URL

Email

Confirm Email

Please list languages spoken:

Practice Name FROM

Practice Name TO

Change or add ID numbers:

Tax Identification Number
Group National Profile Identifier
Individual National Profile Identifier

Tax Identification Number

Please do not include dashes. A change in your TIN may require that you be re-credentialed. If so, you will be notified by the credentialling team.

Apply this TIN to this Practice Name (copy)

Tax Identification Number (additional)

Please do not include dashes. A change in your TIN may require that you be re-credentialed. If so, you will be notified by the credentialling team.

Apply this TIN to this Practice Name

National Provider Identifier - Individual

Group National Provider Identifier

Hours of Operation

Apply this change to this location:

Ages of Patients Seen

18+
0-99
16+
0-21
0-18

Apply this change for ages of patients to this location:

Personnel Changes

Provider Name Change
Office Manager
Credentialing Contact

GROUP Name Change FROM

GROUP Name Change TO

Provider Name Change FROM

Provider Name Change TO

Office Manager

First

Last

Phone

Email

Office Manager (Backup Contact)

First

Last

Phone (backup contact for office manager)

Email (backup contact for office manager)

Provider email update

Credentialing Contact

First

Last

Phone (for credentialing contact)

Credentialing Contact (secondary contact)

First

Last

Email (for secondary credentialing contact)

Phone (for secondary credentialing contact)

Description of other changes

Any other updates?

Referral URL

Comment

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