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
    • *Note: The Electronic Patient Statement fee per page is $0.69 for the first page, additional pages are $0.14 and NCOA is $0.35 each.*
  • 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”

Electronic Patient Statements

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