Provider Information Change Form

As a participating provider, you can now submit changes to your profile online instead of submitting on paper. The following changes may be made through the online request form:

• Addition/Deletion of a physician to/from a practice
• Addition or removal of an office location
• Changes to such information as phone/fax numbers, office hours, hospital privileges
• Change in billing address or tax identification number
• Changes to product participation
• Physician terminations from the network

If you are not able to complete the online form, please complete and fax the below forms to UPMC Health Plan at 412-454-5664.

• 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