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Update Your Information

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. Our Provider Data Management Form, located on the secure CDPHP provider website, is an efficient and time-saving tool to update your practice information online.

Changes to communicate:

  • Practice address
  • Correspondence address
  • Business relationship changes
  • Phone number
  • Office hours
  • Network status
  • Practice scope or member panel changes

Please use the CDPHP Provider Data Management Form to update your information online. You also have the option of using the Practitioner Information Change Request Form* and either mailing it to CDPHP or faxing it to (518) 641-3209. Thank you for helping us ensure that our records are current.

Update your information now

To download and submit this request form, right click and select “Save link as” to save the 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 and submit the form via mail or fax. To submit changes for multiple practitioners or practices using this request form, please complete the Provider Roster (Excel) form, save it, and submit it with the request form.