Add/Remove Provider

Provider Change Information

Directions: Complete this form to inform DHIN of providers who are joining your practice or who are leaving the practice. DHIN will contact you when the mapping has been completed. Please ensure that for new providers, they have been credentialed at the hospitals and labs selected below.

Practice Information
Group/Practice Name:
Change Request Submitted by:
Phone #:
Fax #:
Email:
Address #1:
Address #2:
City:
State:
Zip Code:
Provider Change Information
Add a new provider Remove a provider from the practice
Effective Date of Change:
Provider Name:
Practice Location(if different then above):
Address #1:
Address #2:
City:
State:
Zip Code:
Adding a New Provider(Please complete)
Tests and Services will be ordered from (check all that apply):
	BayHealth Medical Center Beebe Medical Center Christiana Care Health System Doctors Pathology Services LabCorp Account Number: Quest Account Number:

Submit Cancel