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Forms and Guides

ProvidersProvider Address Change Form

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Provider Change Request Forms


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Non-Contracted Provider Address Change Form

If you are provider who does not have a contract with SWHP, follow these steps to update your practice location, billing address, and/or mailing address in our system:

  1. Download the Non-Contracted Provider Address Change Form
  2. Fill out the form. Please Note: ZIP+4 is required for each ZIP code.
  3. Fax the form and a completed W-9 to 1-254-298-6019.

Both the form and your W-9 are required to make changes.

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Provider Address Change Form

Contracted Provider Address Change Form

I want to change my practice location address

Former Location

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New Location

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I want to change my billing information

Former Billing

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New Billing

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I want to change my mailing information

Former Mailing

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New Mailing

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Add new practice location

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