Change of Information

Please provide the requested information below and submit the form. If your tax identification number has changed, please fax an updated W9 to our office at 678-384-3844. Download W-9

Please note that checks must be made payable to the Business Name on the W-9.

If you have questions, please contact our Provider Relations Dept at 800-522-1073, M-F from 8.30am to 5pm ET.
Primary Information
Provider Name*
Effective Date*
Date Format: MM slash DD slash YYYY
Email*
Website
Former Address
Group/Practice
Address
Street Address Address Line 2 City State ZIP Code
Office Contact #
Cell/Alternative #
(For internal use only)
New Address/Additional Office Location
Group/Practice*
Address*
Street Address Address Line 2 City State ZIP Code
Office Contact #*
Cell/Alternative #
(For internal use only)
Fax
Hours*
Handicapped Accessible?*
- Yes
- No
Home Based Office?*
- Yes
- No
EAPC prohibits home-based offices.
New Tax ID #?*
- Yes
- No
Please note, if you have a Tax ID change, please contact our office at 800-522-1073, M-F between 8.30a and 5:00p Eastern time to determine if a new contract is needed for your practice or group.
Mailing Address
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Comments
This field is for validation purposes and should be left unchanged.

CHANGE OF INFORMATION