HEALTHLINK  >>   PROVIDER AND FACILITY DEMOGRAPHIC CHANGE FORM

Provider and Facility Demographic Change Form

If you are a HealthLink participating physician, hospital or other health care professional, please complete this form to record a change of address. Be sure to fill in all sections of the requested information to ensure accuracy.

If you were credentialed by an entity other than HealthLink, please contact them directly to document any changes of address or other information!

Requestor Information
Provider Information
Type of Change

Select the type of change(s) you are making

The effective date cannot be more than 90 days in the past!
Name Change
Current Physical Address
A completed W-9 form is necessary in order to process any TIN changes. If there is more than one TIN change, please submit separate forms for each TIN.
New Physical Address

By completing the New Physical Address section, you will be replacing your Current Physical Address listed above.
If completing this section, the Billing and Admin sections must be completed as well!

A completed W-9 form is necessary in order to process any TIN changes. If there is more than one TIN change, please submit separate forms for each TIN.
Additional Physical Address

By completing the Additional Physical Address field, this will NOT replace your Current Physical Address
If completing this section, the Billing and Admin sections must be completed as well!

A completed W-9 form is necessary in order to process any TIN changes. If there is more than one TIN change, please submit separate forms for each TIN.
Billing Address
(As noted in box 33 of the standard HCFA 1500)
Admin Statement Address
Other