Demographic Change Form
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1DEMOGRAPHIC CHANGE FORM
DATE:
PRACTICE NAME:
TAX ID
NAME AND CONTACT INFORMATION OF INDIVIDUAL COMPLETING THIS FORM:
CONTACT / TITLE
ADDRESS
Street
City
ST
Zip
PHONE
FAX
EMAIL
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DEMOGRAPHIC INFORMATION BEING CHANGED:
CHANGE EFFECTIVE DATE:
This change affects all providers historically at this location?
Yes
No
If no, please list the providers within your group affected by this change:
ADDRESS BEING CHANGED:
Street
City
ST
Zip
Phone
Fax
REASON FOR CHANGE:
Phone number change only
Fax number change only
Location closed; no new location
Location closed – moved to new location (see below)
Location move for providers listed above; location not closed
Other (see below)
If new address, please list below:
ADDRESS:
Street
City
ST
Zip
Phone
Fax
Additional Comments:
UPON COMPLETION, PLEASE FAX TO ONEHEALTH AT: 702-302-4437
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P h o n e : 7 0 2 - 9 9 7 - 0 0 7 9
F a x : 7 0 2 - 3 0 2 - 4 4 3 7
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Parent category: Medical