DC anónimo

Demographic Change Request

Step 1 of 5

Start your Demographic Change Request

Enter your NPI and email to begin your request.

NPI Number *

Email *

Line of Business

Select the line(s) of business for this demographic change request:

Line of Business *

Rendering Provider Information

Rendering Provider NPI *

Rendering Provider Full Name *

Rendering Provider Email *

PRMMIS ID (Vital)

Required if Line of Business includes Vital

Rendering Provider Specialty *

Billing Provider Information

Billing Provider Full Name

Billing Provider NPI

PRMMIS ID (Vital)

Required if Line of Business includes Vital

Billing Provider Email *

Authorized Official Name *

This is the name of the provider's Authorized Official. It must not match the Billing Provider's name, unless they are the same person.

I. Adding New Physical Address

Yes N/A

If location added will be considered for Vital – must submit evidence of location registration in PRMMIS.

Address Line 1 *

Address Line 2

Address Line 3

Country *

State *

City *

Zip Code *

+ 4

Phone Number *

Fax Number

Office Hours *

Enter office hours for each working day. Non-selected days are considered non-working days.

Day	Opening	Closing	Actions
No office hours added

II. Change Physical Address

Yes N/A

If location modified will be considered for Vital – must submit evidence of location registration in PRMMIS.

Indicate Location to be Modified

Address Line 1 *

Address Line 2

Address Line 3

Country *

State *

City *

Zip Code *

+ 4

Phone Number *

Fax Number

Indicate New Physical Location

Address Line 1 *

Address Line 2

Address Line 3

Country *

State *

City *

Zip Code *

+ 4

Phone Number *

Fax Number

Office Hours *

Enter office hours for each working day. Non-selected days are considered non-working days.

Day	Opening	Closing	Actions
No office hours added

III. Delete Physical Address

Yes N/A

IV. Modify Postal Address

Yes N/A

Review & Signature

Confirmation and Modification Attestation

I attest that the information submitted by me in this document is true, correct, and complete to the best of my knowledge.

Practitioner / Authorized Official Name *

This is the name of the Practitioner or Authorized Official. Please verify it matches the authorized person and not the Billing Provider.

Practitioner / Authorized Official Email *

Practitioner / Authorized Official Signature *