Microsoft Word - change form - FINAL.docx … · Web viewTitle: Microsoft Word - change form -...

NOTICE OF CHANGE FORMEmail Form to

[email protected]

Please include all of the information requested along with submission of supporting documentation.Delayed processing may result from an incomplete change request.Change requests are not guaranteed for approval and may require

additional information and verifications along with changes to Contract

Please note that as a contractor with Alliance Behavioral Healthcare, you are required to notify Alliance 30 days in advance to business changes.

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 and Email Address:

Alliance Behavioral Healthcare Notice of Change revised 2.10.18 1

mailto:[email protected]

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

Directions:Submit pages 1, 2, and 25 of this form, and the appropriate completed Section(s)

below, to the address at the bottom of page 25 (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 (if unlicensed, site visit is required prior to approval)

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


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

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


☐ 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 _______________ Complete Section O

☐ Change of Ownership Effective Date _______________ Complete Section P

☐ Change/Update Taxonomy Effective Date _______________ Complete Section Q

☐ Request to add additional CPT Codes Effective Date _______________ Complete Section R

☐ Notification regarding referral acceptance status Effective Date _______________ Complete Section S

☐Contract Withdrawal/Termination Effective Date _______________ Complete Section T

☐Other Effective Date _______________ Complete Section U


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).


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 revised 2.10.18

Change Service/Site Address/Phone

If site is being changed for the main corporate site, a copy of the North Carolina Secretary of State change is required. Attach a copy of the DHSR or Child Placing Agency license (if applicable and in receipt). 30 DAY NOTICE IS REQUIRED. Reminder-Provider is responsible for ensuring that authorizations and billing practices are site and service specific – if location changes are made provider is responsible for obtaining authorizations and ensure that billing practices will correspond to any change.

Site NPI Number:__________________________________

Delete:Street City State Zip

Phone # Fax #

Add:Street

City State Zip

County

Phone # Fax #

Contact Person Name/Title

Handicapped Accessible yes _no

Email


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 [email protected] to discuss removing services. This change requires a revision to your Contract with ALLIANCE BEHAVIORAL HEALTHCARE and compliance with continuation of care guidelines. 30 DAY NOTICE IS REQUIRED

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

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

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 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.


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:




Expiration Date:




Expiration Date:




Expiration Date:

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


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

Individual or Agency Name:


Tax Identification Number:

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

Reason for adding of TIN:


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

Individual or Agency Name:


DELETE TIN: ADD TIN:

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

Please note: TAX ID change requests are not guaranteed for approval. Name and TAX ID changes will require completion of a new application. All Name and TAX ID changes will require submission of the following IRS documents: SS4 Form or 147C Form and copy of W-9.

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 rev 2.10.18

SECTION O: CHANGE OF BUSINESS ENTITY TYPE

Please contact Provider Network Staff at [email protected] 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 rev 2.10.18 18


Alliance Behavioral Healthcare Notice of Change rev 2.10.18 19

SECTION P: Change of Ownership

Please list the first and last names of new owner. Please describe ownership percentages and changes in previous owners:


SECTION Q: UPDATE TAXONOMY

Old Taxonomy:

New Taxonomy:

Site Location address:

Reason for change:


SECTION R: REQUEST TO ADD ADDITIONAL CPT CODES TO CURRENT SITE(PLEASE NOTE THIS IS JUST TO ADD CPT CODES TO SITES THAT ARE ALREADY

CREDENTIALED FOR OUTPATIENT AND/OR E&M CODES)

CPT Codes being requested:

Site Location address:

Reason for change:


SECTION S: ABILITY TO ACCEPT REFERRALSPlease indicate what Site and Services the referral status is being affected

Name of Site:

Address:

Phone # for this site:

Indicate if this is a referral suspension __________________or referral activation___________________

Indicate if this is for Medicaid___________________ or State funded ___________________________

Planned action date:

Contact person at this site:

County in which this site is located:

List all services and corresponding service codes that are being affected by the referral suspension or referral activation (attach additional sheet if needed):

Reason for change:


SECTION T: REQUEST TO VOLUNTARILY WITHDRAW CONTRACT (REMOVAL OF ALL SERVICES AND SITES) – 30 DAY NOTICE IS REQUIRED

Planned closing date (30 day notice required):

Contact person for Consumer Transitions:

Primary Contact person requesting Contract Withdrawal (Owner, CEO, Director):

Current number of Consumers in treatment:

Attach a list of all current consumers (first, last, middle name and date of birth):

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 change, the impact on Consumers and the discharge/continuation of service plan, the impact 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 U: Other

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


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

☐ License Renewal Verification ☐Other Certificate of Insurance: Type

☐:W-9 / IRS Forms (SS4 or 147C) ☐ 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

☐ North Carolina Secretary of State Change Request

☐ Other

☐ Copy of NC Tracks Manage Change Request with Tracking ID number

☐ Other

Your completed CHANGE REQUEST must include:o Page 1 – Demographic Pageo Page 2 – Change Request Checklisto Completed Section corresponding to Change Requesto Page 25 – Documents Checklist and Signature Pageo All Supporting Documentation

Please email to:

Alliance Behavioral Healthcare

[email protected]


Submitted by (Owner, CEO, Director):

Print Name and Title__________________________________________________________

Signature____________________________________________ Date _____________

Phone#_____________________________ Email_______________________________


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