Updated Contact or Address Information 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the Organizational Information section. Fill in the Contracted Entity Name, your name and title as the form submitter, and your email address.
3. Provide the Taxpayer ID (TIN, FEIN), phone number, and fax number. Specify the reason for the update by selecting from options like Contact Information Change or Service Location Change.
4. In Section 1, complete only applicable fields that require change. Attach a current W9 if updating Tax ID or billing address. Enter effective dates for changes and provide new legal name, taxpayer ID, billing address, and contact details.
5. For Section 2 regarding Updated Practitioner Information, fill in practitioner details such as last name, first name, NPI, specialties, and whether they are accepting new patients.
6. In Section 3 for Service Location Change, input old and new location details including addresses and contact information. Indicate if the new location is handicap accessible.

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