Lakeshore Health Network
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Provider Change

Please use this form to notify WHN of changes to physician information, including address, practice name and tax ID number. WHN will 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 WHN at 231-672-6786.

(You must be a WHN Member to complete this form)

*Request Change of

Address

Tax ID

*Date

(mm/dd/yyyy)

*Primary Contact Name

*Phone Number

Email Address

This change effects

*Group Name

*Physician's First Name

*Middle Initial

*Last Name

*Degree

*Specialty:

 

List names of additional physicians:

 

* Required Fields

Address

 

Current Information

New Information

Effective Date of Change
(mm/dd/yyyy)

Practice Name

Address

Suite #

City, State, Zip

Phone

Fax

Office Manager Name

Office Email Address

Tax ID #

Billing Information

 

 

Current Information

New Information

Effective Date of Change
(mm/dd/yyyy)

Practice Name

Billing Address

 

Payee Name

Payee Address

Suite #

City, State, Zip

Phone

Fax

 

Additional Location

Effective Date
(mm/dd/yyyy)

Address

 

Suite

City, State, Zip

Phone

Fax

Tax ID #