Change of Address To change your address, please complete each area in the form below, print and sign, then either fax or mail it to Affinity Healthcare. Your request will be processed within two business days of receipt. *Required field *Policy Number: *This address change is being applied to: (select all that apply) Mailing Address Billing Address Practice Location Old Address *Contact Name: *Practice/Group name: Address 1: Address 2: City: State: Select State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Georgia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee/option> Texas Utah Vermont Virginia Washington (State) Washington DC West Virginia Wisconsin Wyoming Zip: Phone number: ( ) - Fax number: ( ) - Email Address: New Address *Name: *Practice/Group name: Address 1: Address 2: City: State: Select State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Georgia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersy New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee/option> Texas Utah Vermont Virginia Washington (State) Washington DC West Virginia Wisconsin Wyoming Zip: Phone number: ( ) - Fax number: ( ) - Email Address: In order to process this request, please sign here: (this form must be signed by the businessowner) X ____________________________________________