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Demographic Change

Demographic Change

Service Location Address


Practitioner Current Name


Practitioner New Name


Practitioner Name


Service Location Address


New Provider Office Hours


Service Location Address


Service Location Office Hours


Practitioner Current Specialty


Practitioner New Specialty


Follow the instructions for updating the specialty

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


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.