Get the free Change of Provider Request Form pp 214-01-01 (12-2016)
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Behavioral Health and Recovery Services (BARS)
Change of Provider Request Form
As a client/consumer of BARS, you are encouraged to discuss any problems or concerns related to your
treatment directly
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How to fill out change of provider request
How to fill out change of provider request
01
To fill out a change of provider request, follow these steps:
02
Obtain a copy of the change of provider request form from your current provider or from the appropriate governing body.
03
Read all instructions and requirements carefully before filling out the form.
04
Provide your personal information, including your name, address, contact details, and any identification numbers required.
05
Indicate the reason for the change of provider request and provide any supporting documentation if necessary.
06
Include details of your current provider, such as their name, address, and contact information.
07
Provide information about the new provider you wish to switch to, including their name, address, and contact details.
08
Indicate any preferences or specific requirements you have for the new provider.
09
Sign and date the change of provider request form.
10
Submit the completed form to the appropriate authority or directly to your current provider.
11
Follow up with the relevant parties to ensure your request is processed.
Who needs change of provider request?
01
Anyone who wants to switch their current service provider to a different one needs a change of provider request.
02
This could include individuals who are dissatisfied with their current provider's services or pricing, businesses seeking better deals or options, or individuals moving to a new location where their current provider may not be available.
03
Change of provider requests are also common when switching between telecommunications providers, utility service providers, internet service providers, insurance companies, and various other service providers.
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