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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name
This field is for validation purposes and should be left unchanged.
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