Skip to main content

Change Contact Or Provider Profile Information

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 Valid Date
Please select Group or Provider Type

Name of person completing the form

Please enter First Name
Please enter Last Name

Provider Information

Please enter a Group/Provider Name
Please enter Tax Identification Number
Please enter Contact First Name
Please enter Contact Last Name
Please enter a valid Phone number
Please enter Email

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

Please check at least one Option
Please Attest
Information icon Complete all required fields to submit your Provider Profile Change Information Form.

Vision providers, please contact NVA to submit information changes.

Behavioral health providers, please contact Community Care Behavioral Health to submit information changes.