Demographic Update Forms

ATTENTION: If you are currently a provider participating in one or more Health Net of California networks and are having issues registering for the new provider portal, DO NOT submit the network participation forms below.

Instead, please send an email with your contact information so a provider network representative can reach out and assist.

Health Net is committed to providing our providers with the best tools possible to support their administrative needs. We have created an easy way for you to request updates to your information and ensure we receive what we need to complete your request in a timely manner.

If you are a member, report inaccuracies here.

Provider Type *

Physician Hospital Ancillary Medical Group

Include all required fields and populate only the other fields that require updates.

Practitioner Last Name *

Practitioner First Name *

Name *

Address *

City *

State *

ZIP *

Is this a billing address update? *

Yes

Please attach a current W9 *

Practitioner License *

Practitioner NPI *

TIN *

Facility Owner SSN/TIN

Facility Ownership Code

Upload Roster Document Excel, Doc, PDF

Primary Board Certification Date *

Secondary Board Certification Date *

Phone

After Hours Number

Fax

Provider Office email address used for members Only enter an email that you know is HIPAA secure. This is not tied to the email address used for registration on healthnet.com. (Format: example@healthnet.com)

Provider Office email address used for administrative functions

Practitioner Languages (Other than English) Hold Ctrl to select multiple

Office Staff Languages (Other than English) Hold Ctrl to select multiple

Hospital Affiliation

Self-Reported Accessibility Status

Parking (P)

yes no

Exterior Building (EB)

yes no

Interior Building (IB)

yes no

Restroom (R)

yes no

Exam Room (E)

yes no

Exam Table (T)

yes no

Gender

Male Female

Contact Name *

Contact Phone

Contact Email

Effective Date of Change