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Physician/Practice Change Form


 
 

Please use this form to notify HVPA of any changes to practice or physician information. Upon receipt, we will also notify participating health plans of any changes. If you are changing your tax ID number, please be sure to also fax a completed W-9 form to 734-975-1248. All changes will become effective within 30 days of submission.

If you have any questions or concerns, please contact Tracy O'Brien, Provider Relations at 734-973-0137 ext. 414.



Your General Information
   
* Name of Person Submitting Form:
 
* Practice Name:
 

* Job Title:

 
* E-mail Address:
 

Website Address:
(if applicable)

 
* Effective Date of Change:
 
* Required field
     
New Information - You only need to complete sections that are applicable.
     

Primary Practice Location

   

Address:

 

City:

 

Zip:

 

Phone:

 

Fax:

 

Practice Administrator/Manager:

 

Key Contact Name:

 
Key Contact Email Address:
 
     

Secondary Practice Location

   

Address:

 

City:

 

Zip:

 

Phone:

 

Fax:

 

Practice Administrator/Manager:

 

Key Contact Name:

 
Key Contact Email Address:
 
     

Billing Information

   

Practice Name:

 

Billing Address:

 

Payee Name:

 

Payee Address:
(if different)

 

City:

 

Zip:

 

Primary Phone:

 
Private Phone:
 

Fax:

 
     

Physician Personal Information

   

Physician Name:

 

Address:

 

City:

 
Zip:
 

Home Phone:

 

Cell Phone:

 
Pager:
 
     
Tax ID Change
   
Business Name:
 
New ID:
 
* Please note that an updated W-9 must be faxed to HVPA at 734-975-1248
     

Additional Comments:

 


 


 


Copyright © Huron Valley Physicians Association P.C.
2002 Hogback Rd., Suite 3 I Ann Arbor, Michigan 48105 I Phone: 734.973.0137 I Fax: 734.975.1248

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