Changing your Billing or Physical Address  for
Texas Medicaid
(Last updated: 07/31/2000)

To change your address, prepare a letter on your letterhead similar to this and mail it to the address below. Medicaid Provider Enrollment can be reached at 800-925-9126. Wait one week, then call them to make sure your address has been changed. Or you may alternatively (and preferrably) fax it to 512-514-4214.

National Heritage Insurance Company
ATTN: Provider Enrollment
12545 Riata Vista Circle
Austin, TX 78727-6404
Date: July 31, 2000

RE: Provider # P000JM123X

Please note that we have changed our address. Our physical address is now:
 

John Q. Smith, M.D.
1234 Memorial Hwy
Suite 102
Houston, TX  77001


Our billing address is:
 

John Q. Smith, M.D.
PO BOX 711052
Houston, TX  77271-1052
You may contact me at 713-555-1212, extension 1234 for further questions, or you may email me
at jqsmith@advmed.com.

Regards,
 
 

John Q. Smith, M.D.

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