Clearinghouse Enrollment Change Form

Clearinghouse Enrollment Change Form
Submit your request to add, update, or terminate clearinghouse enrollment. Please complete all required fields to ensure timely processing.
Organization Name
Organization Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Contact Full Name
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Enrollment Change
Effective Date of Change
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Change
Affected Clearinghouse Services
Other
Provider Identification Number (e.g., NPI or Tax ID)
Additional Comments or Special Instructions
Should be Empty: