Panel Change Request Form

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1) Submitter Information
To be completed by the Clearinghouse.
Clearinghouse:*
Select one (1) Medicaid Clearinghouse
Other Clearinghouse:
Clearinghouse Contact Name*
Clearinghouse Address
No P.O. Boxes, do not include Office Suite details.
Clearinghouse Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Clearinghouse Contact Email Address*
Virginia Premier will send enrollment confirmation to this address.
2) Provider Group Information
W-9 required
Group / Provider Name*
Group / Provider Tax ID*
Group / Provider NPI
If applicable.
Attach W-9
Please attach a copy of your W-9 form (PDF).
Accepted file types: pdf.

3) Group / Provider Remittance / Billing Address
Please no P.O. Boxes, do not include Suite details.
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Suite Details:
Phone
This field is for validation purposes and should be left unchanged.

1) Submitter Information