Provider Demographic Update Form

Network providers should use this form to update provider demographic information, including:

- Practice address
- Telephone number
- Fax number
- Tax Identification Number
- Billing address
- Location addition
- Location deletion
- Practitioner deletion

Note: If you are a participating provider under Veterans Choice Program (VCP) only, do not complete this form. Refer to instructions for updating demographics for VCP providers.

  • Created: Aug 15, 2013
  • Modified: Feb 7, 2018
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Veterans Crisis Support

Support for your patients who are U.S. Veterans:

  • 1-800-273-8255 Press 1
  • Confidential chat at VeteransCrisisLine.net or text to 838255

Because one small act can make a difference.