Provider Profile Update Request

Step 3 of 3Your update

If you chose “Contact Information”:

Contact Information

New Email Address:

New Phone Number:

New Office Address (if applicable):

If you chose “Professional Headshot”:

Professional Headshot

Upload New Photo

One file. A video can take a minute to upload when you submit.

If you chose “Bio / About Me Section”:

Bio / About Me Section

Please provide the updated bio:

If you chose “Specialties & Areas of Focus”:

Specialties & Areas of Focus

List specialties to add, remove, or update:

If you chose “Insurance Accepted”:

Insurance Accepted

Please list insurance plans to add or remove:

If you chose “Services Offered”:

Services Offered

Please list specialties to add, remove, or update:

If you chose “Availability / Accepting New Clients”:

Availability / Accepting New Clients

Select availability

Currently Accepting New Clients Not Accepting New Clients

If you chose “Telehealth & Location Information”:

If Telehealth & Location Information

Select service type

Telehealth Only In-Person Only Both Telehealth and In-Person Hybrid

If you chose “Credentials / License Information”:

Credentials / License Information

License Type

License Number

State

License Expiration Date

Additional Credential Updates:

If you chose “Languages Spoken”:

Languages Spoken

Please list languages

If you chose “Fees / Private Pay Information”:

Fees / Private Pay Information

Please provide updated fee information

If you chose “Introduction Video”:

Introduction Video

Upload Introduction Video

One file. A video can take a minute to upload when you submit.

Remove my current introduction video.

If you chose “Other”:

Other

Please describe the update you would like to make

Update your profile