Practitioner Information Updates & Changes
To better serve our members, the Centers for Medicare & Medicaid Services (CMS) requires health insurance plans to maintain an accurate roster of participating providers. Please notify CDPHP immediately if any of your information changes.
Changes to communicate:
- Practice address
- Correspondence address
- Business relationship changes
- Phone number
- Office hours
- Network status
- Practice scope or member panel changes
To update your information, complete the Practitioner Information Change Request Form and either mail it to CDPHP or fax it to (518) 641-3209. Thank you for helping us ensure that our records are current.
You must download or right click and select “Save link as” to save this form to your Documents or Desktop before using. It will then open in Adobe Acrobat Reader, allowing you to use the required “Fill & Sign” function to complete the form. Please do not complete the form online; your data will not be saved.
Update your information now
Submitting changes for multiple practitioners or practices?
Please complete the Provider Roster (Excel) form, save it, and submit it with this Provider Information Change Request Form.