Provider Information Change

Federal law requires provider directory information to be reviewed and verified at least every 90 days. To ensure prompt and accurate claims processing and an accurate provider list for our patients and payers, we ask that you update your information regularly by completing this form to notify CBHA of any changes prior to the effective date of the change. There are two forms below. Fill in the first form if you have no changes then click the “No Changes” Button. The second form needs to be filled in when there are changes. Click the submit button at the bottom of that form to send us the changes you have entered.

Practice or facility information

Credentialing information

Tax ID change

Address change

Name change

Phone number change

Specialty change (Includes moving practice to telehealth)

Other changes

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