How do I submit a change of address or location change?

To change your address, it is necessary to complete all three of the following forms. You can find these forms on our Forms page under Address Change Forms.

  • Provider Information Form
  • Location Information Form
  • W-9 form.

You may fax the completed forms to 678-990-1124 or mail to:

Credentialing Department
ActivHealthCare, Inc.
1926 Northlake Parkway, Suite 100
Tucker, GA 30084

These changes are NOT done in the Credentialing Center, but as a separate change between credentialing cycles.

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