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Provider Demographic Change

Let us know your information changes so that we may update our system. Please allow five business days for the change to reflect in our system.

Additional documentation (such as W-9s) can be faxed to Provider Services at 541-768-9364.

If you have questions about this form, please call Provider Services at 541-768-5207 or 1-888-435-2396, 8 a.m. to 6 p.m., Mon.–Fri.

Adding or Removing a Practitioner?

If you are adding or removing a new practitioner or locum practitioner to your group, please complete the forms below and fax to our Provider Services at 541-768-9364.

New Locum Provider Form

Termed Provider Notice Form

* indicator means Required
Your Practice Information
Practice Address Change
Billing Address Change
Phone Number
Fax Number
Name Change
Other Changes

PCP Attestation for InterCommunity Health Network CCO

Do  you need to attest that you meet the criteria for CMS PCP qualification status, as defined in the ACA Section 1202? Instructions are included on the form.