Provider Information Change Form

*Required Information

Date:

Name of Group or Provider:

PCP

Ob-Gyn

Specialist

Ancillary

Chiropractor

Contact Name:*

Provider Number :

Phone:*

E-mail:

Please choose the options you wish to make changes to. The appropriate fields
will then open allowing you to complete your change request.

Add or Remove Physician
Add or Remove Office Location
Office or Physician Information Change
Change Pay to Address or Tax ID
Change in Hospital Privileges
Close/Reopen Panel
Add/Drop Products
Physician Termination
Other Information (Notes)


Change Pay to Address or Tax ID

A group billing address must be the same for every doctor/office under that tax ID. The billing address can only be changed if it is for the whole group with that same tax ID.

Billing Address Change Tax ID Change (Submit W9 form below) Both Billing Address and Tax ID Change

Effective Date:	Required

Old Billing Information
Business Address 1:
Business Address 2:
Suite:
City:
State:
Zip Code:
Phone:
Fax:

New Billing Information
Business Address 1:
Business Address 2:
Suite:
City:
State:
Zip Code:
Phone:
Fax:

Download Tax ID Form (must be faxed to UPMC Health Plan — 412-454-5664)


Change in Hospital Privileges

Changing the hospital affiliation of the doctor or group may affect the products they can provide.

Affiliations to Remove
Hospital:
Privileges:

Hospital:
Privileges:

Hospital:
Privileges:

Affiliations to Add
Hospital:
Privileges:

Hospital:
Privileges:

Hospital:
Privileges:

UPMC Health Plan accepts contacts via e-mail for requests for information or other inquiries only. To enroll, disenroll, or submit an appeal, complaint, or grievance, please contact Member Services by phone or through regular mail. UPMC Health Plan will not accept enrollments, disenrollments, appeals, complaints, or grievances through this website. We apologize for any inconvenience this may cause.