Make an Address Change

What would you like to do? Update a Billing Address Change a Primary Location Add an Additional Location Remove a Location Notify Us of an Office Move

Please submit billing address updates through your Provider Relations staff member if you bill with a SSN as your TIN.

Group/Facility Name *

Tax ID # *

Group NPI # *

Billing Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Billing Address Phone Number *

Please Attach a Completed W9 *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Please submit billing address updates through your Provider Relations staff member if you bill with a SSN as your TIN.

Group/Facility Name *

Group NPI # *

Tax ID # *

Practitioner Name

First Name

Last Name

Practitioner NPI #

Multiple Practitioners

If multiple practitioners are moving, please attach a spreadsheet with their names and NPI Numbers

Old Primary Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

New Primary Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Primary Phone *

Office Hours

Sunday *

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Group/Facility Name *

Tax ID # *

Group NPI # *

Practitioner Name

First Name

Last Name

Practitioner NPI #

Multiple Practitioners

If multiple practitioners are moving, please attach a spreadsheet with their names and NPI Numbers

Additional Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Location Phone Number *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Group/Facility Name *

Tax ID # *

Group NPI # *

Practitioner Name

First Name

Last Name

Practitioner NPI #

Delete Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Location Phone Number *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Use this form when the entire office has moved.

Group/Facility Name *

Group NPI # *

Tax ID # *

Practitioner Name

First Name

Last Name

Practitioner NPI #

Office Moving From

Street Address *

Address Line 2

City *

State *

Zip Code *

Office Moving To

Street Address *

Address Line 2

City *

State *

Zip Code *

Office Phone Number *

Office Hours

Sunday *

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *