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Provider Change of Address (Contracted Provider) (Demographic Update Form)

Thank you for your interest in becoming a Scott and White Health Plan contracted provider.

Please complete this form if you would like to amend your current SWHP contract.

Please complete all fields. Enter N/A if a field is not applicable to you.

* Indicates required information

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Not all required elements have text entered or a value selected.
Please enter values for all of the fields in the color of this box below.
Once done, click the "Submit" button again.
* Type of Address Change:
* Effective Date:
* Provider Last Name:
* Provider First Name:
* Provider Middle Initial:
* Provider NPI:
* Group Name:
* Group NPI:
* TIN:
* Person Submitting Request:
* Person submitting request Phone Num:
Old Billing Address:
Old Billing Address City:
Old Billing Address State:
Old Billing Address Zip Code:
Old Physical Address:
Old Physical Address City:
Old Physical Address State:
Old Physical Address Zip Code:
Old Mailing Address:
Old Mailing Address City:
Old Mailing Address State:
Old Mailing Address Zip Code:
New Billing Address:
New Billing Address City:
New Billing Address State:
New Billing Address Zip Code:
Updated Telephone Num:
Updated Fax Num:
New Physical Address:
SWHP Comments (FOR OFFICE USE ONLY):
New Physical Address City:
New Physical Address State:
New Physical Address Zip Code:
Updated Telephone Num:
Updated Fax Num:
New Mailing Address:
New Mailing Address City:
New Mailing Address State:
New Mailing Address Zip Code:
Updated Telephone Num:
Updated Fax Num:
Alternate Address:
Alternate City:
Alternate State:
Alternate Zip:
Alternate Updated Telephone Num:
Alternate Updated Fax Num:
Comments/Notes
* Attach W-9
(PDF Only)
* Tells us what you think?

Success!

Thank you again for your interest in becoming a Scott and White Health Plan contracted provider.

Please allow 30-45 days before checking on status.

Problem

The form appears to have experienced difficulty during submission.

Please download, fill out, and email the SWHP New Provider Contract Form to ensure timely handling of your request.

Thank you again for your interest in becoming a Scott and White Health Plan contracted provider.

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