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

Date*:

Please enter Valid Date

Group/Provider Type*:

Please select Group or Provider Type

Name of person completing the form

First Name*:

Please enter First Name

Last Name*:

Please enter Last Name

Provider Information

Name of Group Or Provider*:

Please enter a Group/Provider Name

Provider Number:

Tax Identification Number*:

Please enter Tax Identification Number

Contact First Name*:

Please enter Contact First Name

Contact Last Name*:

Please enter Contact Last Name

Phone*:

Please enter a valid Phone number

Email*:

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

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

Provider Termination

Update Race/Ethnicity and Language Information

Other Information (Notes)

Add/Remove a Provider to/from a Practice or Group

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

Add a Provider to a Practice or Group
Remove a Provider from a Practice or Group

Provider Name:

Group/Practice Name:

Tax ID:

Business Address 1:

Business Address 2:

Suite:

City:

State:

ZIP Code:

Phone:

Fax:

Effective Date*:

Please enter Valid Date

Additional Information (Notes):

Is this provider a PCP?*

Please select if this provider is a PCP

Patient Transition Plan*

Patients will stay in this office, but be seen by another provider. If yes, please list providers: Please list providers
Patients will be seen at another office location. If yes, please list the office location: Please list the office location
Other, (please specify): Please provide further explanation

Please select Patient Transition Plan

Add or Remove an Office Location

Please check at least one Option

Add an Office Location
Remove an Office Location

Billing location cannot be removed here. To change your billing location, please complete the section "Change Pay to Address or Tax ID."

Office/Location Name*:

Please enter Office/Location Name

Phone Number:

Fax Number:

Tax ID:

Address Line 1:

Address Line 2:

Suite:

City:

ZIP:

Handicap Accessible:

Office Hours:
	Open	Lunch	Closed
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Effective Date*:

Please enter Valid Date

Provider/Office Information Change

Office/Location Name to Change:*

Please enter Office/Location Name to Change

Old Phone Number:

New Phone Number:

Old NPI Number:

New NPI Number:

Handicap Accessible:

Name Change:

Provider
Practice

Name to Remove:

Name to Add:

New Hours:
	Open	Lunch	Closed
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Effective Date:*

Please enter Valid Date

Change Pay to Address or Tax ID

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

Billing Address Change
Tax ID Change
Both Billing Address and Tax ID Change

Effective Date:*

Please enter Valid Date

Old Billing Information

Business Address 1:

Business Address 2:

Suite:

City:

State:

ZIP Code:

Phone:

Fax:

New Billing Information

Business Address 1:

Business Address 2:

Suite:

City:

State:

ZIP Code:

Phone:

Fax:

Download W9 Form Upload W9 Form

Change in Hospital Privileges

Changing the hospital affiliation of the doctor or group may affect the products they can provide.

Please provide information on changing privileges.

Affiliations to Remove

Hospital:

Please select an Option

Privileges:

Please select an Option

Hospital:

Privileges:

Please select an Option

Hospital:

Privileges:

Please select an Option

Affiliations to Add

Hospital:

Privileges:

Please select an Option

Hospital:

Privileges:

Please select an Option

Hospital:

Privileges:

Please select an Option

Panel Changes

Please check at least one option

Close Panel
Reopen Panel
Age Limitations Please enter Age Limit

Commercial HMO

Effective:

Please enter Valid Date

Commercial PPO

Effective:

Please enter Valid Date

UPMC for Life HMO

Effective:

Please enter Valid Date

UPMC for Life PPO

Effective:

Please Enter Valid Date

UPMC for Life Complete Care

Effective:

Please Enter Valid Date

UPMC Community HealthChoices

Effective:

Please enter Valid Date

UPMC for You

Effective:

Please enter Valid Date

UPMC for Kids

Effective:

Please enter Valid Date

Add/Drop Products

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

Add Product
Drop Product

Commercial HMO

Effective:

Please enter Valid Date

Commercial PPO

Effective:

Please enter Valid Date

UPMC for Life HMO^†

Effective:

Please enter Valid Date

UPMC for Life PPO^†

Effective:

Please Enter Valid Date

UPMC for Life Complete Care^†

Effective:

Please Enter Valid Date

UPMC Community HealthChoices^††

Effective:

Please enter Valid Date

UPMC for You^††

Effective:

Please enter Valid Date

UPMC for Kids

Effective:

Please enter Valid Date

^†Must provide your Medicare number if addingMedicare number

Please enter valid number

^††Must provide your MA (PROMISe) number if adding

Please enter valid number

Provider Termination Form

Termination Date:

Please enter valid Date

Provider Type:

Please check at least one Option

PCP
OB/GYN
Specialist

Specialty*:

Please enter Specialty

Reason for Termination

Please check at least one Option

Relocated within PA
Relocated Out-of-State
Deceased
Retired
PHO Resignation
Voluntary Resignation
No Longer has Par Hospital Privileges

Patient Transition Plan*

Patients will stay in this office, but be seen by another provider. If yes, please list providers: Please list providers
Patients will be seen at another office location. If yes, please list the office location: Please list the office location
Other, (please specify): Please provide further explanation

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.

Update Race/Ethnicity and Language Information

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.

Relationship to provider?*

Please Select Relationship to provider

You have selected other, please specify*

Please Enter Relationship to provider

Please provide the following information for each practitioner actively practicing at the office site (please check all that apply from each dropdown menu):

Provider 1

Provider First Name*:

Please enter Provider First Name

Provider Last Name*:

Please enter Provider Last Name

What is your Race & Ethnicity (check all that apply)*:

Please check at least one Option

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other, (please specify): Please enter your Race
(Declined)

Language(s) spoken (other than English)*

Please check at least one Option

Spanish
Nepali
Arabic
Russian
Mandarin
Hindi
Korean
None
Other, (please specify): Please enter Language Spoken
(Declined)

Add another provider

Do you have language services available through your practice?*

Please check at least one Option

Yes (please check all that apply)
- Translator call-line Please check at least one Option
  - Video
  - Telephonic
- On-site translator or Bilingual Staff (please check all that apply) Please check at least one Option
  - Spanish
  - Nepali
  - Arabic
  - Russian
  - Mandarin
  - Hindi
  - Korean
  - Other, (please specify) Please enter other language for onsite
No
No, but the practice has contacted UPMC Health Plan Provider Services for assistance when a translator or hearing-impaired services are needed.

Additional Information (Notes)

Please enter Notes

By checking this box, I, [_______________], attest that the responses provided heretofore are, to the best of my knowledge, true and correct. 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.

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

Add or Remove Physician
Add or Remove Office Location
Physician/Office Information Change
Change Pay to Address or Tax ID
Change in Hospital Privileges
Panel Changes
Add Products
Drop Products
Provider Termination

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