Priority health provider change form 2026

1. Click ‘Get Form’ to open the priority health provider change form in the editor.
2. Begin by providing a brief explanation of the change in the designated section. Include details such as the physician name, group/facility name, current Tax ID, and NPI number.
3. Fill out the 'Type of Change' section by selecting whether you are leaving a participating provider group or Priority Health Network. Remember that written notice is required 90 days in advance.
4. Complete the 'Demographic Change' section if applicable, including any changes to your address, phone, or fax information. Ensure you check all relevant address types.
5. If changing your name or Tax ID, provide both current and new information in the respective fields. Attach a W-9 for these changes.
6. Review all entries for accuracy and completeness before submitting. Incomplete forms may cause delays.
7. Once completed, fax or email the form to the Provider Information Management department using the provided contact details.

Start filling out your priority health provider change form online for free today!