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Change Contact or 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

Read detailed instructions on completing this form.

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 reviewed and any questions will be addressed before the change can be made.

* Required Information

Please enter Valid Date

Please enter a Group/Provider Name

Please select Group/Provider Type

Please enter Contact Name

Please enter a Group/Provider Name

Please enter Phone Number

Please enter valid Email Address

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

Information iconComplete all required fields to submit your Provider Profile Change Information Form.

If you are not able to complete the online form, please complete and fax the below forms to UPMC Health Plan at 412-454-8225.