If you are currently a Mercer FirstChoice participating provider and would like to update your enrollment information you may do so online by filling out the form below.

• Complete the on-line form.
• Submit the form.
• Form will be received by Mercer FirstChoice via e-mail and changes will be made to provider's file.

Provider Information Update Form

	Provider Name: Tax ID Number: Group Name: Effective Date of Change:     Email:

	Adding ProviderDeleting Provider Practice Location:   Address: City: State:   Phone:   Fax:       Additional Locations:   Address: City: State:   Phone:   Fax:

	Change of Tax ID Number   Old Number: New Number:

	Practice Location   Adding Practice LocationDeleting Practice Location   Address: City: State:   Phone:   Fax:       Additional Locations:   Address: City: State:   Phone:   Fax:

	Change of Remit Address   New Remit Address   Address: City: State:   Phone:   Fax:

	Please describe any change you would like made that is not listed above: