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Demographic Update Forms

ATTENTION: If you are currently a provider participating in one or more Health Net of California networks and are having issues registering for the new provider portal, DO NOT submit the network participation forms below.

Instead, please send an email with your contact information so a provider network representative can reach out and assist.

Health Net is committed to providing our providers with the best tools possible to support their administrative needs. We have created an easy way for you to request updates to your information and ensure we receive what we need to complete your request in a timely manner.

If you are a member, report inaccuracies here.


Provider Type *

Physician

Hospital

Ancillary

Medical Group

Include all required fields and populate only the other fields that require updates.

Is this a billing address update? required*

Excel, Doc, PDF

Only enter an email that you know is HIPAA secure. This is not tied to the email address used for registration on healthnet.com. (Format: example@healthnet.com)
Hold Ctrl to select multiple
Hold Ctrl to select multiple

Self-Reported Accessibility Status

Parking (P)
Exterior Building (EB)
Interior Building (IB)
Restroom (R)
Exam Room (E)
Exam Table (T)

Gender
Last Updated: 02/03/2023