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 provider 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
- Provider terminations from the network
- Update race/ethnicity and language information
Behavioral health providers, please contact Community Care to submit information changes.
The information entered into this form is subject for review by UPMC Health Plan.
Submitting this information change form will not automatically upload to our system but will be reviewed
and any questions will be addressed before the change can be made.
* Required Information
Please enter Tax Identification Number
Please choose the options you wish to make changes to.
The appropriate fields will then open, allowing you to complete your change request.*
If you are adding or removing a provider from multiple office locations,
please enter the primary location here and provide additional locations in the
"Additional information (Notes)" section of the form.
Please check at least one Option
Please select if this provider is a PCP
Please select Patient Transition Plan
Please check at least one Option
Billing location cannot be removed here. To change your billing location, please complete the section
"Change Pay to Address or Tax ID."
Please enter Office/Location Name
Please enter Office/Location Name to Change
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 and tax ID changes require submission of the W-9 form below.
Note:This form will not change the practice location.
To update the practice location, please complete the section "Add or Remove Office Location."
Please check at least one Option
Changing the hospital affiliation of the doctor or group may affect the products they can provide.
Please provide information on changing privileges.
Please check at least one option
Per UPMC Health Plan Provider Agreement, providers must notify the Health Plan 60 days prior to the date of termination.
Please check at least one Option
Please enter valid Date
Please check at least one Option
Please check at least one Option
Please select Patient Transition Plan
Per UPMC Health Plan Provider Agreement, providers must notify the Health Plan 90 days prior to the date of termination.
UPMC Health Plan is committed to advancing the health equity of its membership by providing culturally and linguistically appropriate services and excellent quality of care.
To help ensure that delivery of care meets the cultural and linguistic needs of our members, UPMC Health Plan is asking providers to share their race, ethnicity and language information. Some members feel most comfortable with providers who share their language and racial/ethnic background. By making this information available to our members, they can make informed decisions about their care.
While completion of the questions on this form is entirely voluntary, know that your information will not be used in contracting or credentialing decisions, marketing, or for any discriminatory purpose. The language information of our participating providers is made publicly available per UPMC Health Plan’s Provider Directory. Race and ethnicity information is only made available to individual members upon request.
Please check at least one Option
Please check at least one Option
Please check at least one Option
Please Attest
Complete all required fields to submit your Provider Profile Change Information Form.
Please verify that you are not a robot.
Vision providers, please contact NVA to submit information changes.