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Provider Information Change Request Form

Please complete the form to request the following change (s) to your provider record. Please only update the section identified for the necessary change (s).
- Request to update Clinic Address/Relocation (Section 1)
- Request to add an Address to Existing TIN (Section 2)
- Request to update Billing Information Only (Section 3)
- Request to add a New Provider (Section 4)
- Request to term Provider/Group (Section 5)
Please be advised that all submitted changes to demographic or provider information are subject to review and approval at the discretion of Mercy Network, LLC. Should any additional information or clarification be required to process your request, a member of our team will follow up with you directly. Thank you for your continued partnership.
Section 1: Clinic Address/Relocation
Clinic Name*
Requested Effective Date*
Old Clinic Address*
Please be sure to include Street Address, City, State, Zip Code, Phone and Fax Number
New Clinic Location*
Please be sure to include Street Address, City, State, Zip Code, Phone and Fax Number
Billing Name*
New or Existing Billing Address (Updated W-9 required if updating the Billing Address)*
Please be sure to include Address, City, State, Zip Code, Phone and Fax Number
Please attached W-9
Section 2: Additional Clinic Address to Existing TIN
Requested Effective Date*
Existing TIN*
Existing GNPI*
Clinic Name*
Full Billing Address (please include Street Address, City, State and Zip Code)*
Phone Number*
Fax Number*
If multiple locations are being added, please attach an excel file containing the same information
Drop files here or
Section 3: Update Billing Address and/or TIN (Please attach W-9)
Requested Effective Date*
Clinic Name*
Billing TIN*
Billing Entity Name*
Full Billing Address (please include Street Address, City, State and Zip Code)*
Billing Phone Number*
Billing Fax Number*
Please attach W-9*
Section 4: Request to add a provider to an existing contracted TIN
Requested Effective Date*
Provider Name*
Provider NPI*
Provider Specialty*
Clinic Name*
Full Clinic Address (please include Street Address, City, State and Zip Code)*
Phone Number*
Fax Number*
Please attach excel file if adding multiple providers to an existing contracted TIN
Drop files here or
Section 5: Request to terminate solo provider or terminate the entire group (to include all locations and professionals)
Provider/Group Name*
Clinic Name*
Provider/Group NPI*
Requested Term Date*
Reason for Termination*
If terming multiple providers, please feel free to attach an excel file containing the same information requested above.
If you are requested a change not outlined above, please specify request here:
Submitter Information
Please be advised that all submitted changes to demographic or provider information are subject to review and approval at the discretion of Mercy Network, LLC. Should any additional information or clarification be required to process your request, a member of our team will follow up with you directly. Thank you for your continued partnership.
Name
First Last
Date
Email
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Close my practice to new patients.

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Find my effective date.

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Provider and Payor Networks

Provider Information Change Request Form

Provider Information Change Request Form

Section 1: Clinic Address/Relocation

Section 2: Additional Clinic Address to Existing TIN

Section 3: Update Billing Address and/or TIN (Please attach W-9)

Section 4: Request to add a provider to an existing contracted TIN

Section 5: Request to terminate solo provider or terminate the entire group (to include all locations and professionals)

Submitter Information

Close my practice to new patients.

Find my effective date.

Get help with claim issues on a Mercy Managed Care contract.

Get a list of contracts in which I participate through Mercy Managed Care.