BILLING SERVICES: Change Healthcare Provider Complete Enrollment and Deactivation

It is important to read the following instructions to ensure your enrollment is processed correctly. Please ONLY use the following forms if you are a BILLING SERVICE COMPANY:

• 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”