Please complete this form when adding a location or changing an address, phone number or office hours. If the information being changed pertains to more than one location, please complete a separate form for each location. Please include all clinic NPI numbers to which the change applies. If the tax ID or billing address is changed, a new W-9 will need to be completed.

Fax this form to (612) 632-8830 or email to

Old information:

New information:

Hours of operation (e.g., 9 a.m. - 5 p.m.)