Change Healthcare Provider Complete Enrollment & Deactivation

It is important to read the following instructions to ensure your enrollment is processed correctly.

  • If you are an office wishing to ENROLL FOR THE FIRST TIME, complete the enrollment form “FIRST-TIME Enrollments” and the “ELECTRONIC PATIENT STATEMENTS” enrollment below
  • If you are an office wishing to ADD A NEW PROVIDER to an existing enrollment that has already been complete, complete the enrollment form “EXISTING Enrollments” below
  • If you wish to DEACTIVATE A PROVIDER, complete the enrollment form “DEACTIVATE Provider”

Please complete the following form for FIRST-TIME ENROLLMENTS:

Fields marked with an asterisk (*) are required.

Submitter ID:* 232 231 888

Group / Provider Name: *

Street Address:
City:
State:
Zip Code:

Group Tax ID:*
Group NPI:*

Contact Name:*
Contact Phone:*
Contact Email:*

Services Requested:* (Select all that apply) Claims, ERA & Real Time (Provider Inquiry)Professional Claims (1500 CMS)Institutional Claims (UB04)EFT

Multiple Practices?: YesNo
*If you select Yes for Multiple Practices, please complete a new form for each Practice (unique Tax ID).

Multiple Databases?: YesNo

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Provider:
Credential:*
Tax ID: *
NPI: *

Additional Provider #2
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #3:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #4:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #5:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #6:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #7:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #8:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #9:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #10:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #11:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #12:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #13:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #14:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #15:
Provider:
Credential:*
Tax ID: *
NPI:


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Electronic Patient Statements


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