CHANGE OF INFORMATION

Provider 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.