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Change Provider Name

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Provider Current First Name *

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Provider New First Name *

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Provider New Last Name *

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Date *

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Last Updated: 02/12/2025

Need information in a different language or format? MHS will provide it at no cost to you. Call 1-877-647-4848 (TTY: 1-800-743-3333).

You will need Adobe Reader to open PDFs on this site. Download the free version of Adobe Reader.

Need information in a different language or format? MHS will provide it at no cost to you. Call 1-877-647-4848 (TTY: 1-800-743-3333).

You will need Adobe Reader to open PDFs on this site. Download the free version of Adobe Reader.

Need information in a different language or format? MHS will provide it at no cost to you. Call 1-877-647-4848 (TTY: 1-800-743-3333).

You will need Adobe Reader to open PDFs on this site. Download the free version of Adobe Reader.

Need information in a different language or format? MHS will provide it at no cost to you. Call 1-877-647-4848 (TTY: 1-800-743-3333).

You will need Adobe Reader to open PDFs on this site. Download the free version of Adobe Reader.