NOTICE OF CHANGE FORM

Please include all of the information requested along with submission of supporting documentation.Delayed processing may result from an incomplete change request.

INDICATE WHICH TYPE OF PROVIDER YOU ARE AND PROVIDE ALL REQUESTED INFORMATION

Agency/Group or Hospital Licensed Independent Practitioner (LIP)

Agency name (if applicable):

Federal Tax ID Number:

Agency Primary Address:

Agency Phone Number:

LIP and Credential (if applicable):

Federal Tax ID Number or Social Security Number:

Primary Address:

Clinician Phone Number:

PRIMARY CONTACT PERSON FOR THIS CHANGE REQUEST

Contact Name:

Contact Title/Position:

Contact Address:

Contact Phone:

Contact Email:

Alliance Behavioral Healthcare Notice of Change 1/30/14 1

CHECK THE APPROPRIATE BOX(ES) FOR THE CHANGE(S) REQUESTED

Directions:Submit pages 1, 2, and 20 of this form, and the appropriate completed Section(s)

below, to the address at the bottom of page 20 (signature page).

☐ Name Change Effective Date _______________ Complete Section A

☐ Mailing Address Change Effective Date _______________ Complete Section B

☐ Billing Address Change Effective Date _______________ Complete Section B

☐ Service/Site Address Change Effective Date _______________ Complete Section B

☐ Phone # Only Add/Delete Effective Date _______________ Complete Section B

☐ Remove a Service Location Effective Date _______________ Complete Section C

☐ Remove a Service Effective Date _______________ Complete Section D

☐ Update After Hours Coverage Information Effective Date _______________ Complete Section E

☐ Update Hours of Operation Effective Date _______________ Complete Section F

☐ Update Professional License/Certification Effective Date _______________ Complete Section G

☐ Add a Professional License/Certification Effective Date _______________ Complete Section H

☐ Update Certificate of Coverage for Professional Liability Insurance

Effective Date _______________ Complete Section I

☐ Update Certificate of Coverage for Comprehensive General Liability

Effective Date _______________ Complete Section I

☐ Update Certificate of Coverage for Automobile Liability Effective Date _______________ Complete Section I

☐ Update Certificate of Coverage for Workers Compensation and Occupational Disease Insurance

Effective Date _______________ Complete Section I

☐ Add Tax Identification Number (TIN) Effective Date _______________ Complete Section J

☐ Change Tax Identification Number Effective Date _______________ Complete Section K

☐ Remove an LP Effective Date _______________ Complete Section L

☐ Primary Contact Person Change Effective Date _______________ Complete Section M

☐ Add NPI Effective Date _______________ Complete Section N

☐ Change of Business Entity Type Effective Date _______________ See Section 0

☐ Other ___________________________ Effective Date _______________ Complete Section P

Alliance Behavioral Healthcare Notice of Change 1/30/14 2

SECTION A: NAME CHANGE – COMPLETE AND SUBMIT A NEW FORM W-9

CURRENT Name:

NEW Name:

Reason for Name Change:

You must submit supporting documentation with this form indicating name change (e.g., Drivers License, State issued ID card, marriage certificate(if individual name), change of name documents).

Alliance Behavioral Healthcare Notice of Change 1/30/14 3

SECTION B: ADDRESS/PHONE CHANGE (check all that apply)

Delete:

Change Mailing Addr e ss/Phone

Street City State Zip

Phone # Fax #

Add:Street

City State Zip

County

Phone # Fax #

Contact Person Name/Title Email

Change Billing Address/ Phone

Delete:Street City State Zip

Phone # Fax #

Add:Street

City State Zip

County

Phone # Fax #

Contact Person Name/Title Email

4Alliance Behavioral Healthcare Notice of Change 1/30/14

Change Service/Si te Address/Phone

Delete:Street City State Zip

Phone # Fax #

Add:Street

City State Zip

County

Phone # Fax #

Contact Person Name/Title

Handicapped Accessible yes _no

Email

5Alliance Behavioral Healthcare Notice of Change 1/30/14

SECTION C: REMOVE A SERVICE LOCATION (Closure of site and all services provided at site; not an address change.)

Name of Site:

Address:

Phone # for this site: Fax #

Planned closing date:

Contact person at this site:

County in which this site is located:

Current number of Consumers in treatment:

List all services and corresponding service codes that are being discontinued (attach additional sheet if needed):

Arrangements for discharge/closure: Please attach a narrative to this form that fully explains the rationale for the service removal, the impact on Consumers and the discharge/continuation of service plan, theimpact on Staff, records management plan, and your plan for attending to other obligations detailed in your network Contract with ALLIANCE BEHAVIORAL HEALTHCARE. Adequate notice to Consumers and ALLIANCE BEHAVIORAL HEALTHCARE, as detailed in your Contract, is required.

SECTION D:

REMOVE A SERVICE

Please contact Provider Network Staff via email at providernetwork@alliancebhc.org to discuss removing services. This change requires a revision to your Contract with ALLIANCE BEHAVIORAL HEALTHCARE and compliance with continuation of care guidelines.

Name of service(s) to be removed and corresponding service code(s):

Site(s) where service(s) will be removed:

SECTION E: UPDATE AFTER HOURS COVERAGE INFORMATION

Site Name:

Address: Street City State Zip

County

Previous after hours coverage: New after hours coverage:

Include name, address, phone and fax for after hours coverage.

SECTION F: UPDATE HOURS OF OPERATION

Site Name:

Address:Street City State Zip County

Site Manager: Phone_

Old hours of operation at this site:Monday Tuesday Wednesday Thursday Friday Saturday Sunday

New hours of operation at this site:Monday Tuesday Wednesday Thursday Friday Saturday Sunday

SECTION GG:

UPDATE PROFESSIONAL LICENSE/CERTIFICATIONG

Clinician Name:

Practice Site(s):

Address:Street City State Zip

County:

License Type: _____________Renewal Date: Expiration Date:

Supporting documentation must be submitted with this form.Please attach a copy of the license/certification renewal letter from your Board.

10Alliance Behavioral Healthcare Notice of Change 1/30/14

SECTION H:

CHANGE IN LICENSE/CERTIFICATION

Clinician Name:

Practice Site(s):

Address:Street City State Zip

County:

License Type: ___________Lic # Effective Date: Expiration Date:_____________

Supporting documentation must be submitted with this form. Please attach a copy of your license/certification.

SECTION I: UPDATE CERTIFICATE OF INSURANCE COVERAGE

Type of insurance updated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Type of insurance updated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Type of insurance updated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Type of insurance updated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Copy of Certificate of Insurance (COI) must be submitted with this form.

12Alliance Behavioral Healthcare Notice of Change 1/30/14

SECTION J: ADD ADDITIONAL TAX IDENTIFICATION NUMBER (TIN) – ATTACH FORM W-9

Individual or Agency Name:

Address:Street City State Zip County

Tax Identification Number:

Type of TIN:Social Security Number (SSN) Employer Identification Number (EIN) Other

Reason for adding of TIN:

13Alliance Behavioral Healthcare Notice of Change 1/30/14

SECTION K: CHANGE TAX IDENTIFICATION NUMBER (TIN) – ATTACH FORM W-9

Individual or Agency Name:

Address:Street City State Zip County

DELETE TIN: ADD TIN:

Type of TIN added:Social Security Number (SSN) Employer Identification Number (EIN) Other

Reason for change of TIN:

SECTION L: REMOVE A TREATMENT PROVIDER (LP)

LP/Associate Name: ____

NPI Number:

Site address where LP/Associate will no longer provide services:

County:

Reason for removing LP/Associate:

SECTION M:

PRIMARY CONTACT PERSON CHANGE

Delete this contact person:

Add this contact person:

This contact person is confirmed for the following sites/locations:

County:

Phone: Fax:

Email:

Title:

This Contact is the primary contact for the following issues:

☐ Billing ☐ Contracts ☐ Appointments ☐ Clinical☐ General Administrative☐ Human Resources☐ Other

SECTION N: ADD A NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

NPI Number:

Name of Individual or Site:

Practice Site:

County:

Reason for adding NPI:

17Alliance Behavioral Healthcare Notice of Change 1/30/14

SECTION O: CHANGE OF BUSINESS ENTITY TYPE

Please contact Provider Network Staff at providernetwork@alliancebhc.org to discuss business entity changes as this may require a revision to your current contract with ALLIANCE BEHAVIORAL HEALTHCARE.

Alliance Behavioral Healthcare Notice of Change 1/30/14 18

SECTION P: OTHER

Please describe other changes you wish to make which have not been addressed on this form:

Alliance Behavioral Healthcare Notice of Change 1/30/14 19

DOCUMENTS SUBMITTED AND SIGNATURE PAGE

Please check, or list documents, submitted with this change request:

☐ License Renewal Verification ☐Other Certificate of Insurance: Type

☐:W-9 ☐ Other

☐ Initial License Issue ☐ Other

☐Name Change Documents: Type: ☐ Other

☐ Certificate of Coverage for ProfessionalLiability

☐ Other

☐ Certificate of Coverage for ComprehensiveGeneral Liability

☐ Other

☐ Certificate of Coverage for Automobile Liability

☐ Other

☐ Certificate of Coverage for Workers Compensation and Occupational Disease Insurance

☐ Other

Your completed CHANGE REQUEST must include:

o Page 1 – Demographic Pageo Page 2 – Change Request Checklisto Completed Section corresponding to Change Requesto Page 20 – Documents Checklist and Signature Pageo All Supporting Documentation

Submitted by:

Print Name

Signature Date

Phone # Email

Please email to:ALLIANCE BEHAVIORAL HEALTHCARE

providernetwork@alliancebhc.org

Alliance Behavioral Healthcare Notice of Change 1/30/14 20