Please use this form to notify United Physicians of changes to physician information, including address, practice name and tax ID number.  UP will then notify the appropriate health insurance plans of the changes.  If you are changing your tax ID number, please fax a completed Form W-9 with a letter regarding the change to United Physicians at 248-593-0184.

(Must be a UP shareholder to complete this form)
*Request Change of	Address Tax ID Group Name Additional Location Other
*Date
*Primary Contact Name
*Phone Number
Email Address
This change effects	Only this physician Entire practice
*Group Name
*Physician's First Name
*Middle Initial
*Last Name
*Degree
	List names of additional physicians:
* Required Fields

Address	Primary Secondary	Primary Secondary
	Current Information	New Information
Effective Date of Change
Practice Name
Address
Suite #
City, State, Zip
Phone
Fax
Office Manager Name
Office Email Address
Tax ID #
If you are changing your Tax ID number, please fax your W-9 form with a letter regarding the change to United Physicians at 248-593-0118.
Billing Information
	Current Information	New Information
Effective Date of Change
Practice Name
Billing Address
Payee Name
Payee Address
Suite #
City, State, Zip
Phone
Fax

	Additional Location
Effective Date
Address
Suite
City
State
Zip
Phone
Fax
Tax ID #

Reason for change

Please offer any additional comments that may be helpful in processing your change request.

All changes will be effective no sooner than 30 days after submitting to the plan. If you have any questions or concerns after completing this form, please contact Provider Services at 248.593.0134.