Change
of Information Form
DO WE HAVE YOUR CURRENT INFORMATION?
Participating providers are required to notify Phoebe Health Partners in writing
of any change in practice location, telephone number, billing address, Tax Identification
Number (TIN) or Employer Identification Number (EIN) within ten (10) days of the
occurrence. Click
here
to print the form to report any changes and forward all required documentation via
fax to 229-312-8068.
*Online submission coming soon.
Termination:
If a provider decides to terminate participation with Phoebe Health Partners, written
notification signed by the provider must be submitted to us. You may fax
the correspondence to 229-312-8068.
Please include a signed W9 if this is a change of address or tax id. you can download
the W9 Form
here (opens in new window/tab).
Phoebe Health Partners, Inc.
533 Third Avenue
Albany, Georgia 31701
Phone (229) 312-8061
Phone (800) 474-6323
Fax (229) 312-8068
Contact Us