Provider Updates / Changes

Update or Change Provider 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.

Update or Change Provider Information

Practice Information

Group / Practice Name

10-digit Organization NPI #

Change Request Submitted by:

First Name

Last Name

Phone

Fax

Address Line 1

Address Line 2

City

State

ZIP Code

Provider Change

Add / Remove Provider

Add a new providerRemove a provider from a practice

Effective Date of Change

Provider Name

First Name

Last Name

10-digit Provider NPI #

Provider email

My Practice Location

Is the same as the Address aboveIs different from the Address above

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Information

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DHIN Firsts and Facts

All 46 long term care facilities in the state use DHIN in the care of their residents.

Provider Updates / Changes

Update or Change Provider Information

Update or Change Provider Information

In the News

DHIN Firsts and Facts

Testimonials

Delaware Health Information Network - Empowering Data-Driven Decisions