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Participating Provider Change: Change Facility Information
 

If you have a change for an existing facility, please indicate in the appropriate fields below. We will notify you in writing once the updates have been made to our files. Please enter only your facility name and any new information that should replace what you have previously communicated.

Participating Provider Changes
Old / Current Facility Name   
Effective Date 
New Facility Name
New Address 1
New Address 2
New City
New State
 New Zip
New Phone  
New Fax  

If you are submitting a change for a TIN, please also fax a new W-9 Form to 615-468-4443.
New TIN
Effective Date
New Services
Effective Date
Service No Longer Offered
Contact Name
Contact Phone
Comments  

Thank you.

 

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