Provider Demographic Updates

Ambetter of Tennessee is committed to providing our providers with the best tools possible to support their administrative needs. Providers are strongly encouraged to utilize this form to submit demographic updates. Please fill out the form below with all necessary details, including all required documentation. When selecting the type of update, please review the critical requirements in bold to ensure accuracy in processing your request. Please also be aware that omitting necessary documentation may result in a delay in processing your request. Prior to completing the form, please review the following information:

  • Requests to join our network are not processed using this form. To request to join our network or add a product to your existing agreement, please use our Join Our Network page.
  • Please submit all claims and non-demographic update inquiries through our Provider Portal.
  • This form does not process any changes to member data.
  • This form is not intended to add a new practitioner to an existing group. To add a new practitioner to an existing, participating group, please download our Non-Delegated Credentialing template.

IMPORTANT NOTICE: Please consolidate all practitioner updates from your practice into a single submission. This form is exclusively for demographic updates. Claims, contracting and practitioner enrollment related-inquires must be submitted through their designated channels.

Line(s) of Business Impacted required *
Are you a: (no multiple selection) required *
Please no dashes "-"
Type of Update required *

Accepting Patients Status

Please indicate your patient panel status: required *

Email Address

If updating Email address, do you want to add or remove current email address? required *
If adding an email address please select what type of email address is being added: required *

Name Change (Practitioners Only)

Please upload a copy of supporting, legal documentation for the practitioner name change AND an updated medical license using Supporting Document upload button.

Office Hours

Please enter the service location address that the change in office hours applies to:

Please enter the office hours for each day of the week:

Phone/Fax Number

Please enter the service location that the change in phone/fax numbers apply to:

Service Location (Add/Term)

Please enter the service location address where members can make appointments

Please select which option is needed for this update: required *

Specialty/Taxonomy Update

HAT Code (Specialty)

Please upload a copy of training and education using Supporting Document upload button.

Practitioner Termination

W-9 Submission

Please upload a copy of the W-9 dated within the last 12 months, using the Support Document upload button. W-9’s are needed when updating your TIN/Group NPI billing address.

Are you a: (no multiple selection) required *
Please no dashes "-"
Type of Update required *

Accepting Patients Status

Please indicate your patient panel status: required *

Email Address

If updating Email address, do you want to add or remove current email address? required *
If adding an email address please select what type of email address is being added: required *

Name Change (Practitioners Only)

Please upload a copy of supporting, legal documentation for the practitioner name change AND an updated medical license using Supporting Document upload button.

Office Hours

Please enter the service location address that the change in office hours applies to:

Please enter the office hours for each day of the week:

Phone/Fax Number

Please enter the service location that the change in phone/fax numbers apply to:

Service Location (Add/Term)

Please enter the service location address where members can make appointments

Please select which option is needed for this update: required *

Specialty/Taxonomy Update

HAT Code (Specialty)

Please upload a copy of training and education using Supporting Document upload button.

Practitioner Termination

W-9 Submission

Please upload a copy of the W-9 dated within the last 12 months, using the Support Document upload button. W-9’s are needed when updating your TIN/Group NPI billing address.

Are you a: (no multiple selection) required *
Please no dashes "-"
Type of Update required *

Accepting Patients Status

Please indicate your patient panel status: required *

Email Address

If updating Email address, do you want to add or remove current email address? required *
If adding an email address please select what type of email address is being added: required *

Name Change (Practitioners Only)

Please upload a copy of supporting, legal documentation for the practitioner name change AND an updated medical license using Supporting Document upload button.

Office Hours

Please enter the service location address that the change in office hours applies to:

Please enter the office hours for each day of the week:

Phone/Fax Number

Please enter the service location that the change in phone/fax numbers apply to:

Service Location (Add/Term)

Please enter the service location address where members can make appointments

Please select which option is needed for this update: required *

Specialty/Taxonomy Update

HAT Code (Specialty)

Please upload a copy of training and education using Supporting Document upload button.

Practitioner Termination

W-9 Submission

Please upload a copy of the W-9 dated within the last 12 months, using the Support Document upload button. W-9’s are needed when updating your TIN/Group NPI billing address.