Medicaid change of information form: Fill out & sign online

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Click ‘Get Form’ to open the Medicaid Change of Information Form in our editor.
Begin by filling out the Provider Information section. Enter your Provider Name, National Provider Identifier (NPI), and MS Medicaid Provider Number accurately.
Next, provide your Contact Information. Include your Contact Name, Email Address, and Phone Number to ensure effective communication.
In the Change of Address Information section, select the appropriate box for the address type you wish to change: Servicing, Billing, Mail Other, or Remittance Advice. Fill in the corresponding Street Address, City, County, State, Zip Code, and Phone Number as required.
If changing the 1099 Mailing Address, remember to attach a copy of the W-9 Form along with this submission.
Finally, complete the Authorization for Change section by printing your name, signing the form, and dating it. Ensure all information is accurate before submission.

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How do I update my Medicaid information in Virginia?

We need Medicaid members most up-to-date mailing address and phone number to make sure you get important information about your coverage. Members can make updates: Online at commonhelp.virginia.gov. By calling Cover Virginia at 1-855-242-8282 (TTY: 1-888-221-1590)