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Find a Provider
Your Wellness
Oregon Members
Log In

English
Español
العربية (Arabic)
հայերեն (Armenian)
中文 (Chinese)
हिंदी (Hindi)
Hmoob (Hmong)
日本語 (Japanese)
ជំនួយផ្នែកភាសា (Khmer)
한국어 (Korean)
ພາສາລາວ (Lao)
فارسی (Farsi)
ਪੰਜਾਬੀ (Punjabi)
Русский язык (Russian)
Tulong sa Wika (Tagalog)
ไทย (Thai)
Tiếng Việt (Vietnamese)

Providers
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Demographic Update Forms

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.

Network Participation Request
Medical Policies
Medicare Information
EDI
Participating Provider Operations Information
Provider Demographics Update Form

Affiliation Type required * Direct Network (directly contracting with Health Net) Participating Provider Group (PPG)

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Provider Type required * Physician Hospital Ancillary Medical Group

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Physician

Hospital

Ancillary

Medical Group

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

Effective Date of Change *

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Do you provide behavioral health services? required * Yes No

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If Yes, is your update today regarding: required * Medical benefits Behavioral health services Both Medical and Behavioral health services

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Practitioner Information

Practitioner First Name *

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Practitioner Last Name *

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Billing Tax ID Number (TIN) *

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Practitioner National Provider Identifier (NPI) *

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Facility Information

Facility Name *

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Facility Billing NPI *

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Facility TIN *

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Address *

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City *

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State *

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ZIP *

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Provider Group Information

Provider Group Name *

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Provider Group NPI *

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Provider Group TIN *

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Address *

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City *

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State *

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ZIP *

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Contact Information

Contact Name *

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Contact Title *

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Contact Email *

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Contact Phone

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Select all Demographic Change Types that apply

Facility Ownership Remove owner Add new owner

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Remove Facility Owner Name *

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Remove Facility Owner TIN *

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Remove Facility/Group NPI *

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Remove Facility Ownership Code *

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Add Facility Owner Name *

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Add Facility Owner TIN *

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Add Facility/Group NPI *

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Add Facility Ownership Code *

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Practice Address Remove practice address Add practice address

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Remove Practice Address *

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Remove Practice City *

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Remove Practice State *

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Remove Practice ZIP *

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Add Practice Address *

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Add Practice City *

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Add Practice State *

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Add Practice ZIP *

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Billing Address Remove billing address Add billing address

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Remove Billing Address *

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Remove Billing City *

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Remove Billing State *

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Remove Billing ZIP *

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Add Billing Address *

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Add Billing City *

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Add Billing State *

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Add Billing ZIP *

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Upload W9 *

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Items in the trash will be permanently removed after 30 days.

Practice Phone Remove current phone number Add new phone number

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Remove Phone Number *

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Add Phone Number *

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Fax Line Add new fax number

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Fax Number *

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Provider Office email address used for members New email address

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New email address *

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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)

Provider Office email address used for administrative functions New email address

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New email address *

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Name Remove current name Add new name

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Remove Name

Add New Name

License # or Certification # (if applicable)

Office Hours New office hours

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New Office Hours *

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Office Hours - After Hours New after hours

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New After Hours *

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Accepting New Patients

Practitioner Languages (Other than English)

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Hold Ctrl to select multiple

Office Staff Languages (Other than English)

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Hold Ctrl to select multiple

Hospital Affiliation New hospital name New hospital privileges

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New Hospital Name *

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New Hospital Privileges *

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Self-Reported Accessibility Status

Parking (P) yes no

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Exterior Building (EB) yes no

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Interior Building (IB) yes no

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Restroom (R) yes no

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Exam Room (E) yes no

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Exam Table (T) yes no

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Practitioner Gender Male Female

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Practitioner Ethnicity

Practitioner Age Ranges

Cultural Competency Training Yes No

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Other Professional Training

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Participating Provider Group (PPG)

Please reach out to your PPG to update your demographic information
Contact Us if you have questions

Last Updated: 05/27/2025

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To read PDFs on this site, download Adobe Reader for free here:

Health Net collects some private data about site visitors. Learn more about the data we collect or request your data be removed.

Do Not Sell My Personal Information

Choosing Who Can See My Confidential Medical Information

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