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Change of Provider Request Form Behavioral Health ProvidersMembers may use this form to change their behavioral health provider for a service for themselves, their child or legal dependent. This form

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How to fill out change of provider request

01

To fill out a change of provider request, follow these steps:

02

Obtain the change of provider request form from your current provider or download it from their website.

03

Provide your personal information such as name, address, contact number, and email address in the designated fields of the form.

04

Specify the name of your current provider and the services you currently have with them.

05

Indicate the effective date you would like the change of provider to take place.

06

Select the new provider you wish to switch to and specify the services or package you would like to subscribe to.

07

Review the form to ensure all the information provided is accurate and complete.

08

Sign and date the form.

09

Submit the filled-out form to your current provider either in person, by mail, or through their online submission system.

10

Wait for confirmation from your current provider regarding the status of your change of provider request.

11

Once approved, follow any further instructions given by your current provider to complete the switch to the new provider.

Who needs change of provider request?

01

Anyone who wishes to switch their current provider to another provider needs to fill out a change of provider request.

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What is change of provider request?

Change of provider request is a request made to switch to a different service provider.

Who is required to file change of provider request?

Any individual or organization wanting to switch service providers is required to file a change of provider request.

How to fill out change of provider request?

To fill out a change of provider request, you need to provide your current provider information, desired provider information, reason for switching, and any other required details.

What is the purpose of change of provider request?

The purpose of change of provider request is to inform the current provider of the decision to switch to a different service provider.

What information must be reported on change of provider request?

The change of provider request must include current provider information, desired provider information, reason for switching, contact information, and any other relevant details.

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