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Address/phone number changes

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For non-participating health care professionals

Network applications (behavioral health, dental, facility and pharmacy)

Practice changes/Provider termination

Relocating, retiring, job changes

If you're retiring, moving out of state, or changing provider groups, use this form to notify us. We'll need to terminate your existing agreement with us. If you're moving or changing jobs, you can sign a new agreement for your new practice or location.

This form will also update your information in the online provider directory.

Provider termination form and directory update

Request medical application

Request Part D pharmacy participation

Request workers’ compensation, auto injury, First Health participation

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