Update Provider Information

As a participating provider with Jai Medical Systems, it is important to keep your information up to date. Please use the form below to let us know of any changes to your information. Please only fill out the information that is being changed or updated. Fields marked with an * are required.

If you have any questions regarding this form, please contact the Provider Relations Department at 1-888-JAI-1999.

Provider Information Update
Fields marked with an * are required
Effective Date of Change *
Accepting New Patients?
After Hours Coverage Available?
Completion of Cultural Competency Training?
Accommodations for Physical Disabilities?
Are there any access limitations to the provider?