5/10/2024
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Posted by Provider Relations
In an effort to streamline provider demographic changes, Fidelis Care has created a new electronic Demographic Change Request Form for providers to use. Please use this form to submit demographic changes under a singular TIN currently participating in the Fidelis Care network. In order to expedite the request, all fields on this form are required. If not complete, the request will be delayed.
Once completed, the form can be submitted electronically to SMProviderAttestationUpdates@fideliscare.org. In the subject line of the email, please enter Demographic Change Request for "Your Provider/Group Name" in "Your County" (i.e. Demographic Change Request for ABC Healthcare Group in Ontario County).
Please note: This form should not be used by delegated credentialing entities. Delegated groups should continue to submit termination and demographic change requests through the established process.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.