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.

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.