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Home 9 Provider Updates 9 Demographic Change

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

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.