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SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES BEHAVIORAL HEALTH DIVISION: MENTAL HEALTH SERVICESCHANGE OF PROVIDER REQUEST Return completed form to the receptionist, or Mail to: Grievance Coordinator

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How to fill out change of provider request

01

Obtain a change of provider request form from your current service provider.

02

Fill out the form with all required information, including your personal details, current account number, and the new provider's information.

03

Double-check the form to ensure all information is accurate and complete.

04

Submit the filled-out form to your current service provider via the provided submission method (e.g., online submission, mail, or in person).

05

Wait for confirmation from both your current and new service providers regarding the successful processing of your change of provider request.

06

Follow any further instructions or actions provided by your new service provider to complete the switch and ensure a seamless transition.

07

Once the change of provider is complete, terminate any services with your old provider, if necessary.

Who needs change of provider request?

01

Anyone who wishes to change their current service provider needs a change of provider request. This can be individuals or businesses who want to switch from one service provider to another, such as switching internet service providers, mobile phone carriers, or utility providers.

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What is change of provider request?

Change of provider request is a formal request to switch from one service provider to another.

Who is required to file change of provider request?

Any individual or organization looking to change their service provider 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, new provider information, reason for the switch, and any additional documentation requested.

What is the purpose of change of provider request?

The purpose of change of provider request is to officially notify the current provider of the intent to switch to a new provider.

What information must be reported on change of provider request?

Information such as current provider details, new provider details, reason for the switch, and any supporting documentation must be reported on a change of provider request.

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