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For Providers Provider Account Management

Provider Change of Address (Non-Contracted Provider)

Fill out this form to provide SWHP with updated information for your billing address,

practice location address, mailing address or IRS address.

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

* Indicates required information

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Please enter values for all of the fields in the color of this box below.
Once done, click the "Submit" button again.
* Provider Name:
* Phone Number:
Fax Number:
* NPI Number:
* TIN/SSN:
* Please select an address to change:
* New Mailing Address:
* New Mailing Address City:
* New Mailing Address State:
* New Mailing Address Zip Code:
* New Phone Number:
New Fax Number:
* Effective Date of Change:
* Name of Submitter:
* Title:
* Phone Number:
Email:
Comments/Notes
In order to process your request,
please attach a current completed W-9 with this form and fax to 254-298-6019.
Attach File
(PDF or ZIP Only)
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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.

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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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