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OhioDepartmentofJobandFamilyServices
UtilizationManagementProgramforHospitalServices
ThefollowingnamedindividualwillberesponsibleforcommunicationwiththeOhioDepartmentofJobandFamily
Services, ortheircontractualdesignee,
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How to fill out providers change of contact
To fill out a provider's change of contact form, follow these steps:
01
Obtain the form: Contact the appropriate department or organization to request the provider's change of contact form. They should be able to provide you with the necessary paperwork.
02
Fill in the provider's information: Begin by entering the necessary information about the provider whose contact details are changing. This typically includes their name, identification number, and any other relevant identifiers.
03
Specify the changes: Indicate what specific contact information is changing for the provider. This may include their address, phone number, email address, or any other relevant details. Make sure to provide the new contact information accurately and clearly.
04
Provide supporting documentation: In some cases, you may be required to provide supporting documentation to validate the requested change. This could include proof of address change, legal documentation, or any other necessary paperwork.
05
Sign and date the form: Once all the information has been filled out correctly, sign and date the form as the authorized person making the change. This signature confirms the accuracy of the information provided.
06
Submit the form: Follow the instructions provided on the form to submit it. This can be done electronically, by mail, or in person, depending on the process outlined by the organization or department handling the change.
Who needs a provider's change of contact?
A provider's change of contact form is typically required for individuals or entities that provide services or products to the organization or department responsible for maintaining accurate provider records. This may include healthcare providers, vendors, contractors, or any other party with whom the organization has a professional relationship. The form ensures that the organization has up-to-date and correct contact information for all involved parties, allowing for effective communication and coordination.
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What is providers change of contact?
Providers change of contact is a process of updating contact information for a service provider.
Who is required to file providers change of contact?
The service provider or their authorized representative is required to file providers change of contact.
How to fill out providers change of contact?
To fill out providers change of contact, the service provider needs to submit a form with updated contact information.
What is the purpose of providers change of contact?
The purpose of providers change of contact is to ensure accurate and up-to-date contact information for service providers.
What information must be reported on providers change of contact?
Contact information such as name, address, phone number, and email address must be reported on providers change of contact.
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