Provider change of details form

All fields marked with an * are mandatory.

Name * :

Provider number :

Speciality field * :

Current telephone number * :

Email address * :

Now please enter your details beneath that you wish to change:

New payee name details :

New address details :

Address line 2 :

Address line 3 :

Address line 4 :

Postcode :

New email address * :

New contact fax number :

New contact telephone number :

New secretary name * :

New secretary telephone number :

Are you the provider?: *

I am the Provider named above and I confirm that this information is to the best of my knowledge, true and correct.
I am not the Provider named above and I confirm that I am authorised to request this change of details and this information is to the best of my knowledge, true and correct.

Specialist registration queries

0800 404 9418

Calls may be monitored and/or recorded

Alternatively you can e-mail us at: hcreg@aviva.com

General enquiries regarding a patient's claim including payment of invoices

0800 158 3333

Calls may be monitored and/or recorded

For fee related enquiries call us on:

0800 015 7756

Calls may be monitored and/or recorded