Demographic Information Update

To update any demographic information with Pueblo Health Care, please fill out the fields below or download the demographic update form and mail to:

Pueblo Health Care
400 W. 16th Street
Pueblo, CO 81003

Or fax to 719-584-4038

Or email to sandra_proud@parkviewmc.com

*Denotes required field

Current Practice Name

Change

Effective Date

Physician(s) Affected

Current Information

Practice Name

Physical Address

Address

City

State Example: NY

ZIP Code Example: 12345

Phone Number Example: 123-123-1234 x123

Fax Number Example: 123-123-1234 x123

Billing Address

Address

City

State Example: NY

ZIP Code Example: 12345

Billing Phone Number Example: 123-123-1234 x123

Billing Fax Number Example: 123-123-1234 x123

Tax ID Number

Group NPI Number

Office Manager / Contact

Updated Information

Practice Name

Physical Address

Address

City

State Example: NY

ZIP Code Example: 12345

Phone Number Example: 123-123-1234 x123

Fax Number Example: 123-123-1234 x123

Billing Address

Address

City

State Example: NY

ZIP Code Example: 12345

Billing Phone Number Example: 123-123-1234 x123

Billing Fax Number Example: 123-123-1234 x123

Tax ID Number

Group NPI Number

Office Manager / Contact

*Changes involving Practice Name, Billing Address and TIN require a sample claim form (HCFA) with boxes 25, 31, 32, 33 completed and a copy of a W9.

Typing your full name below will act as an Authorized Signature.

* Authorized Signature

* Today's Date

Demographic Information Update

Current Information

Physical Address

Billing Address

Updated Information

Physical Address

Billing Address

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