GA PSHP FacilityAgency Change Form free printable template

FACILITY/AGENCY CHANGE FORM Submit one Facility/Agency Change Form (FCC) per TIN. Do not submit changes for multiple TIN son FCC. The preferred method for completing the FCC is electronically. Handwritten

How to fill out pshp-ga-facilityagency change form facilityagency

How to fill out GA PSHP Facility/Agency Change Form

1. Obtain the GA PSHP Facility/Agency Change Form from the Georgia Department of Community Health website or your local health department.
2. Fill in the facility or agency name at the top of the form.
3. Provide the current address of the facility or agency.
4. Indicate the type of change (e.g., address change, ownership change, etc.).
5. Complete all required fields with accurate and up-to-date information.
6. Attach any necessary supporting documentation, such as proof of new address or ownership.
7. Review the form for completeness and accuracy.
8. Sign and date the form at the designated area.
9. Submit the completed form to the appropriate department as specified in the instructions.

Who needs GA PSHP Facility/Agency Change Form?

1. Any facility or agency that is part of the Georgia PSHP system and needs to update its information due to changes such as relocation, ownership transfer, or other significant modifications.

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What is GA PSHP Facility/Agency Change Form?

The GA PSHP Facility/Agency Change Form is a document used to report changes regarding healthcare facilities or agencies participating in the Georgia Provider Services Health Program (PSHP).

Who is required to file GA PSHP Facility/Agency Change Form?

All healthcare facilities and agencies that are enrolled in the Georgia Provider Services Health Program and need to report changes to their information or status are required to file this form.

How to fill out GA PSHP Facility/Agency Change Form?

To fill out the GA PSHP Facility/Agency Change Form, you must provide accurate information regarding your facility or agency, including the changes being made, and submit it to the relevant authority as specified in the form's instructions.

What is the purpose of GA PSHP Facility/Agency Change Form?

The purpose of the GA PSHP Facility/Agency Change Form is to ensure that the Georgia Provider Services Health Program maintains up-to-date and accurate information about all participating healthcare facilities and agencies.

What information must be reported on GA PSHP Facility/Agency Change Form?

The form must report information such as the facility or agency name, address, changes in ownership, contact information, and any other relevant details regarding the changes to the facility or agency.