NOTICE OF CHANGE FORM
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- Oswald Austin
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1 MANAGING MENTAL HEALTH, INTELLECTUAL/DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES (FAX) WWW. S A N D H I L L S C E N T E R. O R G V I C T O R I A W H I T T NOTICE OF CHANGE FORM Please include all of the information requested along with submission of supporting documentation. Delayed processing may result from an incomplete change request. Please indicate which type of provider you are and provide all requested information Agency Licensed Independent Practitioner (LIP) Hospital Federal Tax ID: Social Security Number: Primary Phone Number: Primary Contact Person for this change request Contact Contact Title/Position: Contact Contact Contact Please fill out only the section(s) that apply to the change(s) that you are requesting. Directions: Please submit pages 1, 2 and 8 (signature pages) of this form, along with the appropriate completed Section(s), as instructed on page 9 P.O. Box 9, West End, NC Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, & Richmond Counties Available 24 hours a day at
2 Please check the appropriate box(es) for the requested change(s) and complete the corresponding sections Name Change Complete Section A Mailing Address Change Complete Section B Billing Address Change Complete Section B Service/Site Location Address Change Complete Section B Phone # Only Add/Delete Complete Section B Remove A Site Location Complete Section C Remove a Service Complete Section D Update After Hours Coverage Information Complete Section E Update Hours of Operation Complete Section F Update Professional License/Certification Complete Section G Add a Professional License/Certification Complete Section H Update Certificate of Coverage for Professional Liability Insurance Complete Section I Update Certificate of Coverage for Automobile Liability Complete Section I Update Certificate of Coverage for Comprehensive General Liability Complete Section I Update Certificate of Coverage for Workers Compensation and Occupational Disease Insurance Complete Section I Remove a Licensed Independent Practitioner Complete Section J Add a Previously Credentialed Licensed Independent Practitioner Complete Section J Primary Contact Person Change Complete Section K Add NPI Complete Section L Change of Business Entity Type Complete Section M Other: Complete Section N Section A: Name Change Complete and Submit a New Form W-9 Effective Date CURRENT NEW Reason for Name Change: You must submit supporting documentation with this form indicating name change (e.g., Updated Certification of Insurance, Driver s License, State Issued ID Card, Marriage Certificate (if individual name), change of Name Documents). Section B: Address/Phone Change Type of Mailing Billing Phone/Fax Number only Service Site Corporate Delete Address/Phone/Fax Information Delete Delete Phone Number: Delete Fax Number: New Address/Phone/Fax Information New New Phone Number: Contact Person Name/Title: Handicapped Accessible: Yes No New Fax Number: Sandhills Center Notice of Change Form 01/21/2015 Page 2 of 9
3 Section C: Remove a Site Location (Closure of site and all services provided at site; not an address change.) Name of Site: Site NPI #: Phone number for this site: Fax number: Planned closing date: Contact person at this site: Contact County in which this site is located: List all services and corresponding service codes that are being discontinued (attach additional sheet if needed): Service Code(s) to remove: Service Description: Are Licensed Practitioners at this site: Yes License Practitioner Name No (if yes provide names below, attaching additional pages if necessary) Licensed Practitioner NPI Section D: Remove a Service Section Type of Service(s): Medicaid IPRS Population(s) served: I/DD MH SA Ages served: Birth 3 years Child/Adolescent Adult Geriatric Service(s) to Remove (attach additional pages as necessary): Site(s) where service(s) Service code(s) to remove will be removed Service Description Sandhills Center Notice of Change Form 01/21/2015 Page 3 of 9
4 Section E: Update After Hours Coverage Information Effective Date Site Previous after hours coverage: New afterhours coverage: Section F: Update Hours of Operation Site Site Contact: Old Hours of Operation at this Site: Monday Tuesday Wednesday Thursday Friday Saturday Sunday New Hours of Operation at this Site: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Sandhills Center Notice of Change Form 01/21/2015 Page 4 of 9
5 Section G: Update Professional License/Certification Clinician Practice Site(s): License/Certification #: Practitioner NPI: License Type: Renewal Date: Expiration Date: Certification Type: Expiration Date: Supporting documentation must be submitted with this form. Please attach a copy of the license/certification renewal letter from your Board. Section H: Change in License/Certification Clinician Practice Site (s): Practitioners NPI #: License Type: License #: Expiration Date: Supporting documentation must be submitted with this form. Please attach a copy of your license/certification. Section I: Update Certificate of Insurance Coverage *Attach additional pages if needed. * Type of Insurance updated/renewed: Update Certificate of Coverage for Professional Liability Insurance Update Certificate of Coverage for Comprehensive General Liability Update Certificate of Coverage for Automobile Liability Update Certificate of Coverage for Workers Compensation and Occupational Disease Insurance Coverage of: Individual Entity Agency Name of Individual/Entity/Agency: Address/Site Location where insurance is in effect: Expiration Date: ****Copy of Certificate of Insurance (COI) must be submitted with this form. (Submission of a Letter of Intent is NOT sufficient, it must be a Certificate of Insurance (COI) **** Sandhills Center Notice of Change Form 01/21/2015 Page 5 of 9
6 Section J: Remove a Licensed Independent Practitioner (LIP) LIP Reason for Leaving: NPI Number: Section J: To Add a Previously Credentialed Licensed Independent Practitioner (LIP) LIP NPI Number: Originally Credentialed With Name of Agency or Group Originally Credentialed With: Still Employed By: Yes No Effective Date (if No): Currently With Date of Hire: Name of Agency or Group Currently With: Primary Office Phone #: Fax #: Secondary Office Address (if applicable): Phone #: Fax #: Federal Tax ID Number: Type of Practitioner: Fully Licensed Provisionally Licensed License #: Priority Population: MH Adult SA Adult I/DD - Adult MH Child SA Child I/DD - Child Office Hours of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday Arrangements For 24/7 Day Coverage (please describe): Emergency Coverage (please describe): Practitioner Printed Name Practitioner Signature Phone #: ***Supporting documentation must be submitted with this form. Please attach a copy of your License, Supervision Contract/ (if Provisional) and Certificate of Malpractice Insurance for the New Agency/Group*** Date Sandhills Center Notice of Change Form 01/21/2015 Page 6 of 9
7 Section K: Primary Contact Person Change Delete this contact person: Add this contact person: Title: This contact person is confirmed for the following: Site Names Addresses This Contact is the primary contact for the following issues: Billing Contracts Appointments Clinical General Administrative Human resources Others: Others: Others: Section L: Changes to National Provider Identifier (NPI) Number Type of Change: Add national Provider Identifier Revise NPI (NPI correction) Remove NPI This NPI Number is for: Individual Agency Group Site Location Service NPI Number: Name of Individual/Group or Agency: Name of Site Location: Reason for Change: Please submit a copy of the NPPES documentation. Section M: Change of Business Entity Type Change of Business Entity Type Old Entity Type: New Entity Type: Please contact the Provider Helpdesk at (855) or via at providerhelpdesk@sandhillscenter.org to discuss business entity changes as this may require a revision to your current contract with Sandhills Center. Sandhills Center Notice of Change Form 01/21/2015 Page 7 of 9
8 Section N: Other Please describe what type of other changes(s) you wish to make which have not been addressed: A: B: C: D: E: F: G: DOCUMENTS SUBMITTED AND SIGNATURE PAGE Please check or list documents submitted with this change request: License Renewal Verification Other Certificate of Insurance: Type W-9 Other Initial License Issue Other Name Change Documents: Type Other Certificate of Coverage for Professional Liability Other Certificate of Coverage for Comprehensive Other General Liability Certificate of Coverage for Automobile Liability Other Certificate of Coverage for Workers Compensation Other And Occupational Disease Insurance Certificate of Coverage for Malpractice Insurance Other (Add an Already Credentialed Licensed Independent Practitioner) YOUR COMPLETED CHANGE REQUEST MUST INCLUDE THE FOLLOWING: Page 1 and 2 Demographic Page and Change Request Checklist Completed Section Corresponding to Change Request Page 8 Documents Checklist and Signature Page All Supporting Documentation Submitted By (Print Name) Signature Phone #: Sandhills Center Notice of Change Form 01/21/2015 Page 8 of 9
9 PLEASE SUBMIT BY WAY OF: You may or fax the forms to your assigned Credentialing Specialist Or Mail To: Sandhills Center Attention: Credentialing Specialist (If you know your credentialing specialist please include their name) P.O. Box 9 West End, NC Fax # (910) Sandhills Center Notice of Change Form 01/21/2015 Page 9 of 9
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