COVID-19

To protect patients and health care workers, click the button below for the latest updates and information for COVID-19 at Parkview.

COVID-19 Resources

719.584.4000

Main Navigation

Jump to Section Links

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

Our Staff

Ann Bellah - Executive Director
phone (719) 584-4371
fax (719) 584-4038
Email Ann

Sandra Proud - Provider Relations
phone (719) 584-4642
fax (719) 584-4038
Email Sandra

Change Form

400 West 16th Street, Pueblo, CO 81003

719.584.4000

COVID-19

Main Navigation

You are here:

Demographic Information Update

Current Information

Physical Address

Billing Address

Updated Information

Physical Address

Billing Address

Our Staff

Change Form