Practice Address Update

  • Please complete the following information to remove current address information for an existing practice and replace with new address information. This is the address that will be listed in the Neighborhood Health Plan of Rhode Island Provider Directory. If the Tax Identification Number (TIN) of your group has changed, please contact Provider Contracting. (Additional language for mailing and billing address)
  • MM slash DD slash YYYY
  • Does this office meet ADA Accessibility requirements? *
  • Does this site offer the following:
  • Handicap Accessible Building *
  • Handicap Parking *
  • Handicap Restroom *
  • Handicap Accessible Exam Room *
  • Is this site accessible by public transportation?
  • Bus *
  • Subway *
  • Provider(s) Impacted by Update
  • Is this location the provider’s primary correspondence address? *
  • Max. file size: 200 MB.
  • Details for the person submitting the form
  • MM slash DD slash YYYY