Mn uniform practitioner change form 2026

1. Click ‘Get Form’ to open the Minnesota Uniform Practitioner Change Form in the editor.
2. Begin by filling out the 'Demographic Verification and Authorization' section. Enter your name, clinic name, phone number, fax number, email, title, and date. Ensure all fields are completed accurately.
3. In the 'Practitioner Demographic Information for this Request' section, provide details such as last name, first name, middle initial, date of birth (DOB), Social Security Number (SSN), and DEA number. Select the appropriate titles and indicate gender.
4. For adding or removing practitioners, complete the respective sections by entering clinic/hospital names, addresses, phone numbers, and effective dates. Specify if you want to suppress directory information or mark a primary site.
5. If changing demographic data for a practitioner, fill in both old and new information including license numbers and specialties. Attach any necessary documents like a new DEA certificate.

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