Change Form - FINAL

NOTICE OF CHANGE FORM

Email Form to

Pleaseincludealloftheinformationrequestedalongwithsubmissionofsupportingdocumentation.

Delayedprocessingmayresultfromanincompletechangerequest.

Change requests are not guaranteed for approval and may require additional information 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 PROVIDEALLREQUESTEDINFORMATION

Agency/GrouporHospitalLicensedIndependentPractitioner(LIP)

Agencyname (if applicable):

Federal Tax ID Number:

Agency Primary Address:

Agency PhoneNumber:

LIP andCredential (if applicable):

Federal Tax ID Number or SocialSecurity Number:

Primary Address:

ClinicianPhone Number:

PRIMARY CONTACTPERSONFORTHISCHANGE REQUEST

ContactName:

Contact Title/Position:

ContactAddress:

Contact Phoneand Email Address:

Alliance Behavioral Healthcare Notice of Change revised 8.10.171

CHECK THEAPPROPRIATE BOX(ES)FOR THECHANGE(S) REQUESTED

Directions:

Submitpages1,2,and20ofthisform,andtheappropriatecompletedSection(s)

below,totheaddressatthebottomofpage20(signaturepage).

SECTIONA:NAMECHANGE– COMPLETE AND SUBMIT A NEW FORMW-9

CURRENTName:

NEW Name:

Reason for Name Change:

You mustsubmit supporting documentation with this form indicating name change(e.g.,Drivers License, State issued IDcard, marriage certificate(if individual name),changeof name documents).

Alliance Behavioral Healthcare Notice of Change revised 8.10.171

SECTION B:ADDRESS/PHONECHANGE (checkall that apply)

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Delete:

Change Mailing Address/Phone

StreetCityStateZip

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Phone#Fax#

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Add:

Street

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CityStateZip

County

Phone#Fax#

ContactPersonName/TitleEmail

Change BillingAddress/Phone

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Delete:

StreetCityStateZip

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Phone#Fax#

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Add:

Street

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CityStateZip

County

Phone#Fax#

ContactPersonName/TitleEmail

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. Please attach a copy of the MCR form submitted to NC Tracks if you are requesting to use a new NPI number that is not enrolled in NC Tracks. Attach a copy of the DHSR or Child Placing Agency license (if applicable).30 DAY NOTICE IS REQUIRED

If the New Site Address is not currently enrolled in NC Tracks, do you give Alliance approval to upload your new site address with current NPI number to NC Tracks?

Yes No

Site NPI Number:

If no, you are required to submit a Manage Change Request to NC Tracks.

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Delete:

StreetCityStateZip

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Phone#Fax#

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Add:

Street

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CityStateZip

County

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Name ofSite:

Address:

Phone# for this site:Fax#

Plannedclosing date:

Contactperson at this site:

County in whichthis site is located:

Currentnumber ofConsumers intreatment:

List all services andcorresponding servicecodesthat are beingdiscontinued(attachadditional sheet if needed):

Arrangementsfordischarge/closure: Pleaseattachanarrative tothisform that fully explainsthe rationalefortheservice removal, the impact onConsumersand the discharge/continuationofservice plan, the

impact on Staff, records management plan,and yourplanforattending to otherobligationsdetailed in yournetwork Contract with ALLIANCE BEHAVIORAL HEALTHCARE.Adequate noticetoConsumersand ALLIANCE BEHAVIORAL HEALTHCARE,as detailed inyourContract, is required.

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Alliance Behavioral Healthcare Notice of Change revised 2.8.16

Please contact Provider Network Staff via email at to discuss removing services. Thischange requires a revision to your Contract with ALLIANCE BEHAVIORAL HEALTHCARE and compliance with continuation of care guidelines.30 DAY NOTICE IS REQUIRED

Name ofservice(s) to beremoved andcorrespondingservice code(s):

Site(s)whereservice(s)will be removed:

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Alliance Behavioral Healthcare Notice of Change revised 2.8.16

SECTIONE:UPDATEAFTERHOURSCOVERAGEINFORMATION

Site Name:

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Address:

StreetCityStateZip

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County

Previousafterhours coverage:Newafterhourscoverage:

Include name,address,phone andfaxforafterhours coverage.

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Site Name:

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Address:

StreetCityStateZipCounty

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Site Manager: Phone_

Old hours of operationat this site:

New hours of operationat this site:

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G

ClinicianName:

Practice Site(s):

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G

Address:

StreetCityStateZip

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G

County:

License Type:______RenewalDate: Expiration Date:

Supporting documentationmustbe submittedwith this form.

Pleaseattachacopyof the license/certification renewal letter from yourBoard.

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ClinicianName:

Practice Site(s):

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Address:

StreetCityStateZip

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County:

License Type: ______Lic# Effective Date: Expiration Date:______

Supporting documentationmustbe submittedwith this form.

Pleaseattacha copyof your license/certification.

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SECTIONI:UPDATECERTIFICATEOFINSURANCECOVERAGE

Typeofinsuranceupdated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Typeofinsuranceupdated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Typeofinsuranceupdated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

Typeofinsuranceupdated/renewed:

Covered Individual/Entity/Agency:

List address/location where insurance is in effect:

Expiration Date:

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

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IndividualorAgencyName:

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Address:

StreetCityStateZipCounty

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Tax Identification Number:

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TypeofTIN:

Social Security Number (SSN) EmployerIdentificationNumber (EIN) Other

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Reason for adding ofTIN:

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IndividualorAgencyName:

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Address:

StreetCityStateZipCounty

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DELETE TIN: ADD TIN:

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Type of TINadded:

Social Security Number (SSN) EmployerIdentificationNumber (EIN) Other

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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 ofTIN:

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LP/Associate Name:____

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NPI Number:

Site address where LP/Associate will no longerprovide services:

County:

Reason for removing LP/Associate:

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Delete this contact person:

Addthis contact person:

This contactpersonis confirmed forthe followingsites/locations:

County:

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Phone:

Fax:

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Email:

Title:

This Contact istheprimary contact for thefollowing issues:

☐Billing

☐Contracts

☐Appointments

☐Clinical

☐GeneralAdministrative

☐HumanResources

☐Other

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SECTIONN:ADDA NATIONALPROVIDER IDENTIFIER(NPI)NUMBER

NPI Number:

Name ofIndividual or Site:

Practice Site:

County:

Reason for adding NPI:

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Alliance Behavioral Healthcare Notice of Change rev2.8.16

SECTION O:CHANGE OFBUSINESSENTITY TYPE

PleasecontactProviderNetworkStaffat todiscuss businessentitychangesasthismayrequirearevisiontoyourcurrentcontractwithALLIANCE BEHAVIORAL HEALTHCARE.

Alliance Behavioral Healthcare Notice of Change rev2.8.161

SECTIONP:OTHER

Pleasedescribeotherchangesyou wish to make which havenotbeenaddressed onthis form:

SECTIONQ:UPDATE TAXONOMY

Old Taxonomy:

New Taxonomy:

Site Location address:

Reason for change:

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Alliance Behavioral Healthcare Notice of Change revised 2.8.16

SECTIONR: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 REFERRALS

Please indicate what Site and Services the referral status is being affected

Name ofSite:

Address:

Phone# for this site:

Indicate if this is a referral suspension ______or referral activation______

Indicate if this is for Medicaid______or State funded ______

Plannedaction date:

Contactperson at this site:

County in whichthis site is located:

List all services andcorresponding servicecodesthat are beingaffected by the referral suspension or referral activation (attachadditional sheet if needed):

Reason for change:

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

Plannedclosing date (30 day notice required):

Contactperson for Consumer Transitions:

Primary Contactperson requesting Contract Withdrawal (Owner, CEO, Director):

Currentnumber ofConsumers intreatment:

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

List all services andcorresponding servicecodesthat are beingdiscontinued(attachadditional sheet if needed):

Arrangementsfordischarge/closure: Pleaseattachanarrative tothisform that fully explainsthe rationaleforthechange, the impact onConsumersand the discharge/continuationofservice plan, theimpact on Staff, records management plan,and yourplanforattending to otherobligationsdetailed in yournetwork Contract with ALLIANCE BEHAVIORAL HEALTHCARE.Adequate noticetoConsumersand ALLIANCE BEHAVIORAL HEALTHCARE,as detailed inyourContract, is required.

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Alliance Behavioral Healthcare Notice of Change rev 8.10.17

Pleasecheck,orlistdocuments,submittedwiththischangerequest:

YourcompletedCHANGEREQUESTmustinclude:

oPage1–DemographicPage

oPage2–ChangeRequestChecklist

oCompletedSectioncorrespondingtoChangeRequest

oPage24–DocumentsChecklistandSignaturePage

oAllSupportingDocumentation

Please email to:

Alliance Behavioral Healthcare

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