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Has Your Information Changed?

If any of your practice information has changed such as TIN, practice location, change in ownership, etc., please complete this form and FAX to Attn: Provider Services Dept. at 541-768-4513.

Demographic Change Form

Have You Added a Practitioner?

If you are adding a new practitioner and/or locum practitioner to your group, please complete this form and FAX to Attn: Provider Services Dept. at 541-768-4513.

New Locum Provider Form

Has a Practitioner Left Your Group?

If a practitioner is leaving your group, please complete this form and FAX to Attn: Provider Services Dept. at 541-768-4513. Please allow five business days for your changes to take effect.

Termed Provider Notice Form

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.

Talk with our Provider Services representatives 

call us at 541-768-5207 1-888-435-2396 8 a.m. to 6 p.m.
Mon. - Fri.