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Physician/ Allied Health Professional Demographic Change Form

Physician/ Allied Health Professional Demographic Change Form

To request any changes to your demographics including name change please complete and submit this form.

I HAVE PRIVILEGES/MEMBERSHIP AT: (CHECK ALL THAT APPLY)

Carolinas Medical Center

Carolinas Rehabilitation

CHS Pineville

CHS University

CHS Anson

CHS Cleveland

CHS Kings Mountain

CHS Lincoln

CHS Northeast

CHS Union

CHS Stanly

Full Legal Name:

Degree:

Date of Birth:

Change Type:

Group/Office Name:

Street Address:

City:

State:

Zip:

Phone:

Should the address be deleted?

Yes

No

New Address:

Type of Address

Group/Office Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Preferred Email:

Change Confirmed with Practioner Office

NAME CHANGE: (REQUIRED, PLEASE SEND A COPY OF YOUR GOVERNMENT ISSUED DOCUMENT)

Previous Full Name:

Current Full Name:

Reason:

Marriage

Divorce

Other

Requested By:

Requester's Name:

Requestor's Email:

Phone Number:

Organization or Department:

Effective Date of Change

Other Comments:

Authentication

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