Report Updates to the Provider Directory

Please fill out and submit the following form to report updates to the provider directory. Required fields are labeled with an *.

Identify Yourself
First Name: *
Last Name: *
Phone:
Email:
Who Are You?: 
Identify Provider

Identify the provider in the directory that needs updating.

Type:
First Name: * Middle Initial:
Last Name: *
Updated Values

Enter the proposed new values below. Only enter values for fields that need updating.

First Name: Middle Initial:
Last Name:>
Address:
City: State: Zip:
Phone:
Fax:
Clinic Hours/Days:
Languages:
Email:

Comments:


You may also report updates to the provider directory via:
  • email: directoryinfo@chgsd.com
  • phone: 1-800-224-7766
  • or mail:
       2420 Fenton St., Suite 100
       Chula Vista, CA 91914
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