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For providers (change)

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Provider Information Update Form

Use this form to notify us about changes in your practice. Fields marked with an asterisk (*) are required fields.

Dental providers:

Participating in-network dental providers, please visit asurisdental.com to submit changes for your practice information.
Out-of-network dental providers practicing within our service area, please submit this form.

Behavioral health providers: Please use the Behavioral Health Practitioner Areas of Clinical Focus Form to update your areas of clinical focus or modalities.

Network termination or closing a practice

If you are terminating a network affiliation or closing a practice, do not submit this form.

Refer to your provider agreement and our Contact Us page for instructions and address for submitting a network termination notice.
Exception: Removing one provider from a group contract only can be requested by submitting this form.
- Please select one option below to remove an individual provider.

Individual provider leaving a practice?

Note: Add the individual provider leaving a practice details in the Comment box at the bottom of the form.

Is the provider retiring or no longer practicing?*

Yes

No

Is the provider leaving employment to work at another practice?*

Yes

No

Is the provider moving from one location to another within your same practice (Tax ID)?*

Yes

No

Your details

Please enter your contact information for this change request.

First name*

Last name*

Phone *

Email*

Organization name(s)

Effective date of change*

MM/dd/yyyy

Tax ID*

Electronic contracting

All provider agreement notifications are made by email. Contractual documents must be reviewed and signed electronically by the person delegated (the legal contract signatory) to receive contractual notifications and sign provider agreements on behalf of contracted physicians or other health care professionals at your practice.

Legal contract signatory email

We recommend you use an email account dedicated to contracting that remains with the provider instead of an individual's email account. This will ensure future contractual communications are received regardless of staffing changes.

Who is this change for?

Change applies to*

The provider only

The entire organization

Type of change request*

This is new information, not a change

This is a change to existing information

Please complete both the Old and New Information sections if you are submitting updates to existing providers.
If you are adding a new provider to your practice, please complete only the New Information fields below.

Billing address

Is the billing address the same as physical address?*

Yes

No

Is the billing phone number the same as the physical address phone number?*

Yes

No

An Asuris representative may contact you by phone to verify billing address changes.

Practice information

Practice website URL

Accepting new patients?*

Yes

No

Practice primary care?*

Yes

No

Telehealth services?*

Yes

No

Interpreter services?*

Yes

No

Evening hours/weekend?*

Yes

No

Do you accept urgent referrals?*

Immediately (within three hours)

Within 24 hours

Within 48 hours

Within 3 days

Within 7 days

I do not accept urgent referrals

Cultural health practices?

In addition to interpreter services, all patient communications are offered in languages commonly used by the populations in our service area.*

Yes

No

In addition to ADA accessibility, additional services are offered to patients with functional limitations (such as extended visit times, care giver coordination, scheduling flexibility).*

Yes

No

Do you ensure cultural competency (language, beliefs, social structures) in the delivery of person-centered care.

Yes

No

Are you a Hospital and Free-Standing Facility Based Practitioner (HBFB) at this location?* If yes, we require a signed copy of your HBFB application. Please fax to 1 (888) 289-1313 after submitting this online form.*

Yes

No

Specialize in lesbian, gay, bisexual, transgender (LGBTQ+) care?*

LGBTQ+

Prefer not to disclose

Specialty

(List all that apply)

Degree(s)

(List all that apply)

Other languages

(List all that apply)

Provider race or ethnicity

Select

Gender

Select

Other, please specify

Correct pronouns

Select

Provider data validation

Who should we email to validate information about your practice for our provider directory?*

Comments

Please provide any additional information to assist us with your change request:

Details for an individual provider leaving a practice
Locating the appropriate provider record
Other information that you require be updated

We process updates within 10 business days and you will NOT receive a notification it has been completed.

If you have questions after 10 days, please contact the Provider Contact Center.

Please DO NOT submit another request.

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