Physician Change of Address Form | Children's National

Change of Address

To ensure referring doctors receive feedback on their patients, including faxed discharge reports from the Emergency Department or other inpatient units, please fill out the form below to update your address.

Personal Information

First Name:

Middle Initial:

Last Name:

Suffix:

Degree:

(MD, RN, etc.)

Specialty:

NPI Number:

Practice Name:

Number of physicians in practice:

Names of other physicians in the practice:

Email Address:

Practice Website:

Mailing Address Information

Street Address Line 1:

Street Address Line 2 (Optional):

City:

State:

Zip Code:

Phone Number:

Fax Number:

Are patients seen at the above location?

Yes
No

Other Locations for Your Practice

2nd Location Name:

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip Code:

Phone Number:

Fax Number:

3rd Location Name:

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Secure Fax Machine/Server Number:

Select one of the following options for receipt of patient correspondence and other information from Children’s National:

Please type in what you see above:

For additional changes or locations, call 202-476-4418. If your address has changed, remember to update your information with the national NPI registry to improve referral processing.

Physician Relations

Physician Access Line
Call 202-476-4880

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Physician Liaisons
Call 202-476-4418

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Change of Address

Physician Relations