Update a Billing Address

Is the provider wanting the updates for * Only their checks and EOB to be mailed to a new address? Only for the tax reporting address for the IRS tax document (Form 1099)? Both for checks, EOB and for the tax reporting address for the IRS tax document (Form 1099)? Form 1099 is a tax document issued to a recipient and reported for the IRS/State for income tax reporting purposes.

Group/Facility Name *

Provider One ID

Tax ID *

Group NPI # *

Billing Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Billing Address Phone Number *

Please Attach a Completed W9 *

Comments

Updated Requested By:

First Name *

Last Name *

Date *

Email *

Phone Number *

Additional Attachments