Use this form to notify us about changes in your practice. Fields marked with an asterisk (*) are required fields.

Dental providers:

• Participating in-network dental providers, please visit regencedental.com to submit changes for your practice information.

• Out-of-network dental providers practicing within our service area, please submit this form.

TriWest providers:
TriWest uses us as their network subcontractor. Any demographic changes submitted to us are automatically sent to TriWest if your organization is currently participating in a TriWest program. This reduces the administrative burden of having to notify multiple payors when updates are made to rosters, practice locations, or when adding or removing a credentialed provider to your practice.

• If your organization is not yet participating with TriWest, you may email a request to contract for TriWest programs once you have completed credentialing with us.

Behavioral health providers: Please use the Behavioral Health Practitioner Areas of Clinical Focus Form to update your areas of clinical focus or modalities.

If you are terminating a network affiliation or closing a practice, do not submit this form.

• Refer to your provider agreement and our Contact Us page for instructions and address for submitting a network termination notice.
• Exception: Removing one provider from a group contract only can be requested by submitting this form.
  • Please select one option below to remove an individual provider.