Forms to Update Existing Provider Information

All forms must be submitted with an original signature by mailing to:

Unisys Provider Enrollment Unit

P. O. Box 80159

 Baton Rouge, La. 70898-0159

 

  • Direct Deposit / EFT (Electronic Funds Transfer) Form

  • EDI Contract and Power of Attorney Forms

  • File Update Form

  • Group Linkage/Unlinkage & Working Relationship Forms

  • MDs & DOs Specialty Change Form

  • Personal Care Services (PCS) Specialty Form

  • School Based Health Center (SBHC) Specialty Form

  • Submitter/Provider Unlinkage Form