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County of Los Angeles Department of Mental Health8939387366Local Mental Health PlanREQUEST FOR CHANGE OF Proliferate/CONFIDENTIAL/For optimum accuracy, please print clearly using capital letters:To

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How to fill out change of provider form

01

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

02

Fill out personal information including name, address, and account number.

03

Indicate the reason for the change of provider.

04

Provide contact information for the new service provider.

05

Submit the completed form to your current service provider.

Who needs change of provider form?

01

Anyone who wishes to switch service providers for a particular service.

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What is change of provider form?

Change of provider form is a document used to inform a service provider about a change in the current service provider.

Who is required to file change of provider form?

The individual or organization who is changing service providers is required to file the change of provider form.

How to fill out change of provider form?

To fill out the change of provider form, you need to provide your current service provider information, new service provider information, and reason for the change.

What is the purpose of change of provider form?

The purpose of the change of provider form is to ensure a smooth transition from one service provider to another.

What information must be reported on change of provider form?

The change of provider form must include current service provider details, new service provider details, effective date of change, and reason for the change.

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