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Priority health provider change form 2026
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- Click ‘Get Form’ to open the priority health provider change form in the editor.
- 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.
- 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.
- Complete the 'Demographic Change' section if applicable, including any changes to your address, phone, or fax information. Ensure you check all relevant address types.
- If changing your name or Tax ID, provide both current and new information in the respective fields. Attach a W-9 for these changes.
- Review all entries for accuracy and completeness before submitting. Incomplete forms may cause delays.
- Once completed, fax or email the form to the Provider Information Management department using the provided contact details.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.8 Satisfied (100 Votes) |
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