Provider Directory Data Update Form

If your last name has changed, please email ProviderRelations@ndbh.com and we can update our records.

If you want to review or update other information such as trainings, age groups, special services, languages, or your ethnicity please visit our full demographic update form here.

Please click on one of the following choices to confirm your appointment availability timeframe to treat a Lucet member:

The active service/billing addresses that we have on your account along with the Tax ID number we currently have. If these are correct you can select "No" to the question below, if you select "Yes" you will be able to update all of your address information. Please do not click the "Remove" next to addresses, that will NOT remove your addresses.

This is the active service/billing addresses that we have on your account along with the Tax ID number we currently have. If these are correct you can select "No" to the question below, if you select "Yes" you will be able to update all of your address information. Please do not click the "Remove" next to addresses, that will NOT remove your addresses.

If you use your primary as a billing address your billing address may not show here, NO further action is required.

A primary practice address is required for each Tax ID #. If you only have one practice location, it will be the primary address. All additional practice locations with the same Tax ID are considered secondary addresses. List one billing address only for each Tax ID in the billing address portion of the form. You must have a primary address for a Tax ID

Each address has the following update options. Please understand what each update option for addresses means:

Keep as is- This will keep the address and Tax ID # active in our systems
Remove/Replace- The provider will no longer be able to bill for dates of service using the address and Tax ID # as of 30 days from today.
Unsure- No changes to the address and Tax ID # will be made in our systems at this time. An email verification will sent to the provider to verify current addresses and Tax ID #.

If you are a group practice making updates on behalf of a provider, please only update the applicable address and Tax ID information to your group practice for the provider.

You will not be able to edit the Practice Name, Tax ID, or Practice Location fields. If you need to make changes to one of these fields you will need to use the “Remove/replace” response to the “Active Address” question and create a new entry with the new or corrected information.

You must have a service location linked to the Tax ID you are adding below.