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Add a New Provider or Term an Existing Provider

Add a New Provider or Term an Existing Provider Local

If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required.

 

EHP Roster Template (Excel)
(Roster template revised 02/04/2022)

Update Requested By


Provider Name


Practitioner will be termed from all locations associated with this TIN.

Update Requested By


Disclaimer

If you are terming more than 15 providers, you can submit your changes by emailing the details to EHPprovidercontracts@primehealthcare.com


Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Provider Name


Practitioner will be termed from all locations associated with this TIN.

Update Requested By


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