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

Click here for 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  
Date:* Please enter Valid Date
Name of Group or Provider:* Please enter a Group/Provider Name
PCP Ob-Gyn Specialist Ancillary
Chiropractor Dental PPO Provider Vision PPO Provider Extender (CRNP, CNM, CRNA)
Please select Group/Provider Type

Contact Name:* Please enter Contact Name
Provider Number:* Please enter a Group/Provider Name
Phone:* Please enter Phone Number
E-mail:* 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
Add/Remove a Provider to/from a Practice or Group
Add or Remove an Office Location
Office or Provider Information Change
Change Pay to Address or Tax ID
Change in Hospital Privileges
Close/Reopen Panel
Add/Drop Products (Applies to Medical Network Providers Only)
Provider Termination
Other Information (Notes)

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.