Provider Change of Address Form 



Please Note: Before completing this form, refer to the Change of Address-Provider Requirements (LINK) for detailed 

instructions on filling out this form. 
You can update your information with MassHealth via the Provider Online Service Center, using the “Manage Provider Information” 
feature. Alternatively, use this form to notify MassHealth of any updates to your information. This form is available at www.mass.gov/masshealth.
com as an online fillable form. As stated in 130 CMR 450.223(B), providers must notify MassHealth within 14 days of any 
change. To view our regulations, please go to www.mass.gov/masshealth. 


For any change in your legal entity, address, or check mailing address, you must submit an updated Request for Taxpayer 
Identification Number and Certification (Massachusetts Substitute W-9 form) with an original signature. You can download this 
form from our Web site at www.mass.gov/masshealth. 


Providers are reminded that provider numbers are not transferable. For certain providers, approval of the new site or a new 


application may be required when there is a change to the “doing business as” address. 
Please note that MassHealth cannot process changes to legal entity addresses or check mailing addresses that are not 
accompanied by a corresponding Massachusetts Substitute W-9 form with an original signature. 


Fill in the following details. If any of the addresses below are left blank, the address will default to 
the one currently on file. 
MassHealth provider ID/service location: NPI no.: 
(A) Legal Entity Address (P.O. boxes are NOT acceptable.) 
(MassHealth provider ID/service location) 
(NPI no) 
Must include a Massachusetts Substitute W-9 form. Cannot fax or e-mail. 

Address: 
(Effective date) 
(Zip code) 
(State) 
(City) 
(Address) 


City: 
(Fax no) 
(Telephone no) 


State: 

Zip code: 

 Effective date: 
Telephone no.: 
(TTY number (for people with partial or total hearing loss) 


 Fax no.: 
TTY number (for people with partial or total hearing loss): 
(E-mail address) 
(Contact name) 
Contact name: 


 E-mail address: 

(B) “Doing Business As” Address (P.O. boxes are NOT acceptable.) 
Please refer to Change of Address—Provider Requirements for detailed instructions. 

Address same as in section A 
(A) Unchecked
C 
(C) Unchecked
(D) Unchecked
D E 
(E) Unchecked
Address: 
(Address) 
City: 
(City) 
State: 
(State) 
Zip code: 
(Zip code) 
Effective date: 
(Effective date) 
Telephone no.: 
(Telephone no) 
Fax no.: 
(Fax no) 


TTY number (for people with partial or total hearing loss): 
(E-mail address) 
(Contact name) 
(TTY number (for people with partial or total hearing loss) 
Contact name: 

 E-mail address: 

(C) Billing Address 
Address same as in section 
(Address) 



(A) Unchecked
A 
(B) Unchecked
B 
(D) Unchecked
D 
(E) Unchecked
E 
Address: 
(Effective date) 
(Zip code) 
(State) 
(City) 
City: 
(Fax no) 
(Telephone no) 


State: 

Zip code: 

 Effective date: 
Telephone no.: 
(TTY number (for people with partial or total hearing loss) 


 Fax no.: 
TTY number (for people with partial or total hearing loss): 
(E-mail address) 
(Contact name) 
Contact name: 

 E-mail address: 

CAD (Rev. 07/10) 


(D) Check Mailing Address (same as remittance address on W-9) (D) Check Mailing Address (same as remittance address on W-9) 
Must include a Massachusetts Substitute W-9 form. Cannot fax or e-mail. 

Address same as in section 
(Address) 



(A) Unchecked
A 
(B) Unchecked
B 
(C) Unchecked
C 
(E) Unchecked
E 
Address: 
(Effective date) 
(Zip code) 
(State) 
(City) 


City: 
(Fax no) 
(Telephone no) 


State: 

Zip code: 

 Effective date: 
Telephone no.: 
(TTY number (for people with partial or total hearing loss) 


 Fax no.: 
TTY number (for people with partial or total hearing loss): 
(E-mail address) 
(Contact name) 
Contact name: 


 E-mail address: 

(E) Information Mailing Address (for bulletins and transmittal letters) 
Address same as in section A 
(A) Unchecked
B 
(B) Unchecked
(C) Unchecked
C D 
(D) Unchecked
Address: 
(Address) 
City: 
(City) 
State: 
(State) 
Zip code: 
(Zip code) 
Effective date: 
(Effective date) 
Telephone no.: 
(Telephone no) 
Fax no.: 
(Fax no) 


TTY number (for people with partial or total hearing loss): 
(E-mail address) 
(Contact name) 
(TTY number (for people with partial or total hearing loss) 
Contact name: 

 E-mail address: 

How do you want to receive bulletins and transmittal letters? Please check one:
(E-mail (fastest) E-mail address) 



(How do you want to receive bulletins and transmittal letters? Please check one) Unchecked
(Postcard (up to 10 days later than e-mail) Unchecked 
Postcard (up to 10 days later than e-mail)

 E-mail (fastest) E-mail address: 

I certify under the pains and penalties of perjury that the information on this form and any attached statement 
that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my 
knowledge. I also certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf 
of the provider. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, 
omission, or concealment of any material fact contained herein. 

Provider’s signature: 

(Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to 
sign on behalf of a legal entity, are not acceptable.) 

Printed legal name of provider: 
(Printed legal name of provider) 


Printed legal name of individual signing: 
(Printed legal name of individual signing) 


(if the provider is a legal entity) 

Date: 
(Date) 


Contact tel. no.: 
(Contact tel. no) 


Please return the completed form to the following address or fax number. 

MassHealth 

ATTN: Provider Enrollment and Credentialing 

P.O. Box 9118 
Hingham, MA 02043 
Fax: 617-988-8974 
Note: Changes to the legal entity address or check mailing address are not acceptable by fax or e-mail 
because they must include a Massachusetts Substitute W-9 form with an original signature. 

If you have any questions, please call MassHealth Customer Service at 1-800-841-2900 or contact them 
by e-mail at providersupport@mahealth.net.