Thrive - Provider Updates - Premera
  • PREMERA

    PREMERA

  • PROVIDER UPDATE FORM

  • GENERAL INFORMATION

  • Format: (000) 000-0000.

  • UPDATE TYPE

    Please check all that apply
  • Change Applies to Entire Practice/Group*
  • Change Applies to Specific Practice or Group Location(s)*
  • Change Applies to Individual Provider(s). (For more than 1 Practitioner, submit 1 form per practitioner)*
  • Effective date of change*
     / /

  • CHANGE OF PRACTICE NAME

  • CHANGE OF OWNERSHIP/TAX ID

  • Browse Files
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  • MAKE CHANGES TO AN EXISTING LOCATION ADDRESS

    *Note: For more than 1 location, please submit this form again
  • Change applies to (check all that apply)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • ADD OR REMOVE PRACTICE LOCATION(S) FROM ENTIRE GROUP

  • # of Locations to ADD/REMOVE (if more than 4, please fill out a second form)
  • 1st Location - ADD/REMOVE?
  • Format: (000) 000-0000.
  • 2nd Location - ADD/REMOVE?
  • Format: (000) 000-0000.
  • 3rd Location - ADD/REMOVE?
  • Format: (000) 000-0000.
  • 4th Location - ADD/REMOVE?
  • Format: (000) 000-0000.
  • Do you need to add practitioners to these locations?

  • ADD/REMOVE/UPDATE PRACTITIONER INFORMATION

  • To credential a new provider, see premera.com/wa/provider/reference/join-our-network/

  • Accepting new patients
  • Remove Practitioner from Practice Location(s)

  • Please review to ensure all information is correct PRIOR to submission.

    Upon submitting, this form will be automatically emailed to Premera, Thrive Practices, and a copy sent to the email listed below in the "Individual's email" field.

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