Form 3109, Provider Information Change

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Effective Date: 11/2023


Updated: 11/2023


Form 3109 is used by Hemophilia Assistance Program (HAP) providers when they need to update their business information.


Submit completed forms electronically to, by fax to 512-776-7417 or by mail to Provider Relations, Mail Code 1938, P.O. Box 149030, Austin, TX 78714-9947.

Detailed Information

Provider Information 

Provide your business name, National Provider Identifier (NPI), and Primary Taxonomy Code. Forms will be returned if this information is not included.

Address Information

Providers check the appropriate option and enter the current address and new or modified address to make modifications to the physical or accounting/mailing address on file. Physical and alternate physical addresses are locations where services are rendered to clients and cannot be a P.O. Box. 

Any modifications or additions to the alternate physical address information for Medicare-enrolled providers must match the address on file with Medicare. Note: Chemical dependency treatment facilities (CDTFs) are exempt from this requirement.

Performing providers (providers within a group) cannot change accounting information. Performing provider address updates are limited to addresses already associated with the group and currently on file. The update will be denied if the address is not on file for the group.

You cannot submit claims for services that are rendered at an alternate physical address or a new practice location until it has been approved and added to your enrollment record.

Communication Preferences 

Indicate how you would like to receive communications from state health care programs. Note: Selecting “mail” will result in communications being sent to the provider’s mailing address on file.

Tax Information

Federal Tax Identification Number (TIN) changes for individual practitioner providers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. A federal W-9 form is required for all TIN changes and legal name changes.

Change of Provider Status

Provide any comments needed (e.g., plan disenrollment, move or specialty change).

Required Signature

The authorized provider must sign Form 3109 for all changes requested for individual provider information. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider information.