NOTICE OF CHANGE FORM

Pleaseincludealloftheinformationrequestedalongwithsubmissionofsupportingdocumentation.

Delayedprocessingmayresultfromanincompletechangerequest.

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 Phone:

Contact Email:

Alliance Behavioral Healthcare Notice of Change 1/30/141

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

Directions:

Submitpages1,2,and20ofthisform,andtheappropriatecompletedSection(s)

below,totheaddressatthebottomofpage20(signaturepage).

☐Name Change / Effective Date ______/ Complete Section A
☐Mailing Address Change / Effective Date ______/ Complete Section B
☐BillingAddress Change / Effective Date ______/ Complete Section B
☐Service/Site Address Change / Effective Date ______/ Complete Section B
☐Phone# OnlyAdd/Delete / Effective Date ______/ Complete Section B
☐Remove a Service Location / Effective Date ______/ Complete Section C
☐Remove aService / Effective Date ______/ Complete Section D
☐UpdateAfterHours Coverage Information / Effective Date ______/ Complete Section E
☐UpdateHoursof Operation / Effective Date ______/ Complete Section F
☐Update Professional License/Certification / Effective Date ______/ Complete Section G
☐Adda ProfessionalLicense/Certification / Effective Date ______/ Complete Section H
☐Update Certificate of Coverage for Professional Liability Insurance / Effective Date ______/ Complete Section I
☐Update Certificate of Coverage for ComprehensiveGeneral Liability / Effective Date ______/ Complete Section I
☐Update Certificate of Coverage forAutomobile Liability / Effective Date ______/ Complete Section I
☐Update Certificate of Coverage for WorkersCompensationandOccupationalDiseaseInsurance / Effective Date ______/ Complete Section I
☐Add TaxIdentification Number(TIN) / Effective Date ______/ Complete Section J
☐Change Tax Identification Number / Effective Date ______/ Complete Section K
☐Remove anLP / Effective Date ______/ Complete Section L
☐Primary Contact Person Change / Effective Date ______/ Complete Section M
☐Add NPI / Effective Date ______/ Complete Section N
☐Changeof Business Entity Type / Effective Date ______/ See Section 0
☐ Other ______/ Effective Date ______/ Complete Section P

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 1/30/141

SECTION B:ADDRESS/PHONECHANGE (checkall that apply)

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Alliance Behavioral Healthcare Notice of Change 1/30/14

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

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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/Title
Handicapped Accessible yes / _no / Email

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Alliance Behavioral Healthcare Notice of Change 1/30/14

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 1/30/14

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.

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 1/30/14

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:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

New hours of operationat this site:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

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Alliance Behavioral Healthcare Notice of Change 1/30/14

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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Alliance Behavioral Healthcare Notice of Change 1/30/14

ClinicianName:

Practice Site(s):

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Alliance Behavioral Healthcare Notice of Change 1/30/14

Address:

StreetCityStateZip

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Alliance Behavioral Healthcare Notice of Change 1/30/14

County:

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

Supporting documentationmustbe submittedwith this form.

Pleaseattacha copyof your license/certification.

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Alliance Behavioral Healthcare Notice of Change 1/30/14

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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Alliance Behavioral Healthcare Notice of Change 1/30/14

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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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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Alliance Behavioral Healthcare Notice of Change 1/30/14

Phone:

Fax:

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Alliance Behavioral Healthcare Notice of Change 1/30/14

Email:

Title:

This Contact istheprimary contact for thefollowing issues:

☐Billing

☐ Contracts

☐Appointments

☐Clinical

☐GeneralAdministrative

☐HumanResources

☐Other

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Alliance Behavioral Healthcare Notice of Change 1/30/14

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 1/30/14

SECTION O:CHANGE OFBUSINESSENTITY TYPE

PleasecontactProviderNetworkStaffat todiscuss businessentitychangesasthismayrequirearevisiontoyourcurrentcontractwithALLIANCE BEHAVIORAL HEALTHCARE.

Alliance Behavioral Healthcare Notice of Change 1/30/141

SECTIONP:OTHER

Pleasedescribeotherchangesyou wish to make which havenotbeenaddressed onthis form:

Alliance Behavioral Healthcare Notice of Change 1/30/141

DOCUMENTSSUBMITTEDANDSIGNATUREPAGE

Pleasecheck,orlistdocuments,submittedwiththischangerequest:

☐License Renewal Verification / ☐OtherCertificate ofInsurance:Type
☐:W-9 / ☐Other
☐Initial LicenseIssue / ☐Other
☐Name ChangeDocuments: Type: / ☐Other
☐Certificate of Coverage forProfessional
Liability / ☐Other
☐Certificate of Coverage forComprehensive
General Liability / ☐Other
☐Certificate ofCoverage forAutomobile Liability / ☐Other
☐CertificateofCoverageforWorkers CompensationandOccupationalDisease Insurance / ☐Other

YourcompletedCHANGEREQUESTmustinclude:

oPage1–DemographicPage

oPage2–ChangeRequestChecklist

oCompletedSectioncorrespondingtoChangeRequest

oPage20–DocumentsChecklistandSignaturePage

oAllSupportingDocumentation

Submitted by:

PrintName

SignatureDate

Phone #Email

Please email to:

ALLIANCE BEHAVIORAL HEALTHCARE

Alliance Behavioral Healthcare Notice of Change 1/30/141