Mn provider change form 2026

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4.8 out of 5

121 votes

The Provider Demographic Change Form is a document used by BCBSMN Provider Data Operations to update provider information, including address, phone number, name changes, office hours, and hospital affiliations. It emphasizes the importance of submitting complete and accurate forms to avoid processing delays and includes sections for confirming current information, making changes, and ensuring cultural competency training. The form must be completed for each location affected by the changes.

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Click ‘Get Form’ to open the mn provider change form in our platform's editor.
Begin by checking the purpose of your request. Select all applicable changes such as address, phone, or name changes.
Confirm your current information by entering details that match your W-9 form, including Legal Business Name, DBA Name, and NPI/UMPI.
If you are making changes, check the relevant boxes and provide updated information for each section, including physical and mailing addresses.
Fill in the hospital affiliations and indicate if you are accepting new patients. Provide office hours for both regular and urgent care.
Complete the accessibility and cultural competency sections to ensure compliance with standards.
Finally, enter any additional information needed and provide your name, title, email address, and phone number before submitting the form via email.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (121 Votes)

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