Provider Change Form

You can select any one of the Avēsis provider change forms by clicking on the name of the form listed here in blue:

1. 1. Service Location Update fax, phone, and email — This form should be filled out when the provider or group would like to update their phone number, fax number or business email address.
2. 2. Address Change New Billing Address Location (BU) — This form should be filled out when the provider would like to change their current billing address to a new one.
3. 3. Add Avēsis Provider Existing Business or Service Location — This form should be filled out when a participating group would like to add a new Avesis credentialed provider to their group and/or service locations.
4. 4. Removal Provider from Group — This form should be filled out when you want to remove a provider from participation with your group because the provider is no longer employed.
5. 5. Tax ID Change (No Change of Ownership) — This form should be filled out when the provider or group would like to change the existing TAX ID, but no change of ownership is occurring.
6. 6. Practice Sold Under New Ownership — This form should be filled out when a current business or group is changing ownership.
7. 7. Existing BU Add New Service Location — This form should be filled out when the participating provider or group would like to add an additional service location.
8. 8. Address Change New Service Location (Old Address Closing) — This form should be filled out when the provider location is closing and you would like to notify Avēsis of the new location that you have moved to.
9. 9. Closing Business Unit or Service Location — This form should be filled out when the provider or group is closing a business or service location..
10. 10. Avēsis Provider New Business Add New Business Entity — This form should be filled out when the participating provider or group would like to add a new business.

Simply follow the steps on each Provider Change form and fax your request to the Network Provider Information Department at 855-591-3564.

Please be sure all information is completed and proper documentation is attached or your request will NOT be processed. Allow 10 business days for update.