Practitioner Demographic Update Form

Meridian is committed to providing our providers with the best tools possible to support their administrative needs. We have created an easy way for you to request updates to your information and ensure we receive what we need to complete your request in a timely manner. If you are an existing participating practitioner, simply complete and upload the form below to communicate any needed demographic updates.

Practitioner Change Form Template (Excel | .xslx)

Practitioner Update Form Upload *

W-9 Form Upload (required for all billing/remittance address changes)

Name Change Documentation Upload (required for name changes/updates)

Update requested by:

First Name: *

Last Name: *

Contact Email: *

Contact Phone Number *

Need to review your existing information or have a question? If you are a contracted provider you can visit our Provider Directory to review your information. Please note that hospital-based and midlevel providers will not show in the directory. If you are a non-contracted provider, please call Provider Services at 1-888-437-0606. Our Contact Us page is always available for general questions as well.

Last Updated: 11/07/2024