The Minnesota Uniform Practitioner Change form is used by all Minnesota health plans to provide a common format for data collection.   
Submit your updates online: 
HealthPartners contracted providers are encouraged to submit practitioner and location changes using the secured Provider portal tool “Provider Data Profiles” for easiest and most efficient communications. 
•	Get confirmation of your submissions and access to check for completion.
•	Changes done on-line can also generate a PDF for you to easily submit to other payers.
•	Log in at HealthPartners.com/Provider. If you need an account or access to this valuable tool, contact your portal’s site administrator or contact us.
Submit your updates manually: 
Paper form submissions may take longer to process than online submissions, and confirmations of receipt or completion are not provided.  In the event you need to submit the Minnesota Uniform Practitioner Change form manually there are two options: 
Ø Preferred: email completed forms to ProviderData@HealthPartners.com. Ø Fax completed forms to 952-853-8703.
Questions?  Contract Provider Relations. 
 MINNESOTA UNIFORM PRACTITIONER CHANGE FORM - Revised May 2021
Add – Remove – Change Demographic Data for Credentialed Practitioners and Specialists. Not Subject to Credentialing: ER Physician, Hospitalist Pathologist, Radiologist, Anesthesiologist, CRNA, Neonatologist, Dietitian, Therapists (PT; OT; SLP), Audiologist – check with entity if unsure.       
*If "NO", practitioner will not be included in the directory.
Demographic Verification and Authorization 
Completed and authorized on behalf of the practitioner by: 
Name/Title: 	 Date: 

FAX #

:

 

E

-

Mail:

Organization Name: 
Phone #: 
Practitioner Demographic Information for this Request 
*****As shown on your state License***** 

Last:

 

First:

 

MI:

 

SSN

:

 

Title: 

  MD 

 DO 

  MBBS 

  DC  

  DPM 

  DDS 

Other 

Title: 

DOB:

 

  

Female

 

  

Male

 

License Number

:

 

State

:

 

DEA: 

State

:

Type I NPI: 

Languages spoken fluently to treat patients:

Race and/or ethnicity: (The following information is optional and may be used in provider directories to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members.)  
Check here if you do not wish for your race and/or ethnicity to be displayed in provider directories: 

CHANGE Practitioner Demographic Data 	
Effective Date of Change:  	
Old: 	New: 
Last Name: 	Last Name: 

First Name: 

MI: 

First Name: 

MI: 

Specialty: 

Specialty: 

License #: 

State: 

License #: 

State: 

DEA #: 

DEA #: 

	

	
	
List additional practice locations to ADD/REMOVE on the Site Location Addendum and attach to this form. 
 Check here if you have additional Site Location Addendum forms attached. 	
MN Uniform Practitioner Change Form & Site Addendum Form May 2021
THE FOLLOWING SITE LOCATION ADDENDUM FORM IS USED IN CONJUNCTION WITH THE MINNESOTA 
UNIFORM PRACTITIONER CHANGE FORM WHEN ADDING OR REMOVING PRACTITIONERS FROM MORE THAN TWO SITES.  THIS FORM WILL ONLY BE ACCEPTED WHEN IT IS ACCOMPANIED BY A COMPLETED MINNESOTA UNIFORM PRACTITIONER CHANGE FORM. 
SITE LOCATION ADDENDUM 
(Please make as many extra copies as necessary) ADDITIONAL LOCATION(s) FOR: 

MN Uniform Practitioner Change Form & Site Addendum Form May 2021