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Provider Change of Address

(Contracted Provider - Demographic Update Form)

Please complete all fields.

Problems!

Not all required elements have text entered or a value selected. Please enter values for all of the fields in the color of this box below. Once done, click the "Submit" button again.

Type of Address Change

Effective Date

Provider NPI

Provider First Name

Provider Middle Initial

Provider Last Name

Group Name

Group NPI

TIN (w/o dashes)*

Requester Name

Requester Phone

Requester Email

Physical Address

Old Physical Address

City

State

ZIP

New Physical Address

City

State

ZIP

Phone

Fax

Billing Address

Same as Old Physical Address

Old Billing Address

City

State

ZIP

Same as New Physical Address

New Billing Address

City

State

ZIP

Phone

Fax

Mailing Address

Same as Old Physical Address

Old Mailing Address

City

State

ZIP

Same as New Physical Address

New Mailing Address

City

State

ZIP

Phone

Fax

Alternate Practice Location

Alternate Practice Address

City

State

ZIP

Phone

Fax

Comments/Notes

Attach W-9 (PDF Only)

Tell us what you think

Success!

Thank you for submitting your address change request to Baylor Scott & White Health Plan. Please allow 30-45 days for processing and 30 days before checking on status.

Problem

The form appears to have experienced difficulty during submission.

If you encounter the issue again, please email HPPROVSERVICES@BSWHealth.org.

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