Get Change Request Form Dhs Ri

Filling out the Change Request Form Dhs Ri is an essential step for providers to ensure that their information remains current and accurate. This guide will provide you with a systematic approach to completing the form online, ensuring a seamless experience.

Follow the steps to correctly fill out the Change Request Form.

1. Click 'Get Form' button to access the Change Request Form and open it in the editor.
2. In the 'Provider Name' field, enter the full name of the provider as it appears on official documents. Make sure it is accurate for identification purposes.
3. Fill in the 'Old Service Address' to indicate the previous service address that needs to be replaced.
4. Provide the 'New or additional service address' where applicable. Ensure that this is the updated location for service delivery.
5. Input a contact 'Phone Number' linked to the new service address for further communication.
6. Repeat similar steps for 'Old Pay-To Address,' 'New Pay-To Address,' and their respective phone numbers to update billing information.
7. Fill out 'Old Mail-To Address' and the corresponding 'New Mail-To Address' along with a contact phone number.
8. Update the 'Old Billing Service Address' with the new information similarly. Ensure to include phone numbers.
9. If applicable, check the box for 'Change in ownership interest or corporate status' and provide requested details, including new owners' names and addresses.
10. Specify the 'Date of Change of Ownership Interest' and briefly describe the process that led to this change.
11. Document the 'New Corporate Status,' and provide information on any changes to certification conditions, including previous and current conditions and dates.
12. If there has been an adverse action against the license, outline the action taken, by which agency, and the effective date of this action.
13. If a bankruptcy filing has occurred, include the 'Date of Filing,' 'Type,' and contact information for the attorney and trustee involved.
14. Provide your 'Authorized Signature' along with the date to certify that the information provided is accurate.
15. Print your name and title in the designated fields. If necessary, attach additional paper for more information.
16. Review all entries for accuracy, then save changes to ensure all information is retained.
17. Conclude by downloading, printing, or sharing the completed form as needed. Once done, you can either fax the Change Request Form to (401) 784-3892 or mail it to the specified address.

Complete your Change Request Form online today to keep your information up to date.