Skip to Main Content

Demographic Change

What do you want to do? required *

Change Phone Number

Service Location Address

Update Requested By

Change Practitioner Name

Practitioner Current Name

Practitioner New Name

Update Requested By

Add/Remove a Language Spoken

Update Requested By

Update Practitioner Office Hours

Practitioner Name

Service Location Address

New Provider Office Hours

Update Requested By

Update Service Location Office Hours

Service Location Address

New Service Location Office Hours

Update Requested By

Update Specialty

Choose all applicable networks required *
What do you want to do? required *

Blank Standard Cred Roster Template
(Template revised in 09/2024)

Blank Standard Cred Roster Template
(template revised in 09/2024)

Update Requested By

Practitioner Name

Update Requested By

Change Accepting New Members Status

Choose all applicable networks required *

Practitioner Name

Service Location Address

Practitioner Type required *
Is the Practitioner Accepting New Members required *

Update Requested By

Change Panel Size (PCP Only)

Choose all applicable networks required *

Practitioner Name

Blank Standard Cred Roster Template
(Template revised in 09/2024)

Service Location Address

Update Requested By

Change Age Restriction

Choose all applicable networks required *

Practitioner Name

Blank Standard Cred Roster Template
(Template revised in 09/2024)

Service Location Address

Practitioner Type required *

Update Requested By

 

This form will send your message to SilverSummit Healhtplan as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with SilverSummit Healthplan through email, you accept associated risks. SilverSummit Healthplan does not accept responsibility or liability for any loss or damage arising from the use of email.

To ensure the safety of your protected health information (PHI), please send a secure email message directly to our Contract Coordinators at NVSS_ProviderQuality@SilverSummitHealthPlan.com  while providing the Group NPI in reference.

Additionally, status updates are achieved with a direct email to our Contract Coordinators at NVSS_ProviderQuality@SilverSummitHealthPlan.com, including the Group NPI and practitioner’s NPI(s) as applicable.