NEW! Provider Demographic Change and Termination Request Forms
5/21/2024
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Posted by Provider Relations
In an effort to streamline provider demographic changes and provider termination requests, Fidelis Care has created two new electronic forms for providers to use. Please use these forms to submit changes under a singular TIN. In order to expedite the request, all fields on the forms are required. If not complete, the request will be delayed.
Forms available on fideliscare.org:
Once completed, the forms can be submitted electronically to SMProviderAttestationUpdates@fideliscare.org. In the subject line of the email, please enter Demographic Change/Termination Request for "Your Provider/Group Name" in "Your County" (i.e. Demographic Change Request for ABC Healthcare Group in Ontario County).
Please note: These forms should not be used by delegated credentialing entities. Delegated groups should continue to submit termination requests through the established process.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.