Provider Update Form

Please email the forms to or fax it to 1.623.374.4592 (the 1 is required in front).

If you are:
- A new provider beginning to submit claims to insurance payer for the first time
- Have made any changes to your practice information

It is imperative that each insurance payer in which you have billed or plan to bill is informed of the changes to prevent:
- Claims Processing and Payment delays
- Confirm receipt of accurate 1099 insurance form issue at the end of the year

FMBS will be responsible for updating any changes on the claim form for submission, but is the responsibility of the Provider to update this information directly with the payer.

FMBS has provided the attached form and a list of address for the major insurance payers.
Please address the envelope Attn: Provider Relations

United Health Care
POB 30555
Salt Lake City UT 84130
POB 14079
Lexington KY 40512
POB 182223
Chattanooga TN 37422
POB 14601
Lexington KY 40512
Health Net
POB 14225
Lexington KY 40512
POB 2924
Phoenix AZ 85062
(only for providers who practice in AZ)

If you are a provider in a different state the BCBS address will be your local BCBS, please contact FMBS for the correct address.

*Practice additions/changes received by the insurance payer takes approximate 90 business days to be added in the system. This may affect correspondence received and claims processing.

Anthem BC CA

Provider Update Form

W-9 Form