Get Bgeorgiab Collaborative Aso Change Of Information Bformb

Completing the Georgia Collaborative ASO Change Of Information Form is an important step for approved providers looking to modify their information with the Department of Behavioral Health and Developmental Disabilities. This guide will provide you with clear and detailed instructions to efficiently fill out the form online.

Follow the steps to complete the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by checking the type of change you are reporting. This section allows you to indicate whether you are updating agency information, point of contact information, or address information, among other options.
3. Enter the Georgia Medicaid/Peachcare for Kids provider number that the changes will apply to. Remember that you can only modify one provider number per form.
4. In the 'Current Provider Information' section, provide the full name of the agency or business as it is currently recorded with DBHDD. Also, include the current mailing address and, if applicable, the Tax Identification number.
5. If you are reporting a name change, go to the 'New Agency Name / Location / Tax ID Information' section. Fill in the new legal agency name and any applicable DBA name, location name, and attach the required Taxpayer ID details.
6. In the 'New Address / Telephone / Fax Number Information' section, indicate if the corporate mailing address, billing location address, or any other relevant addresses are changing. Provide the new address details including city, state, and zip code.
7. For the 'Point of Contact Information', select the appropriate role and fill in the new contact details including name, phone number, and email as needed.
8. Accurate information for the 'Licensure/Accreditation/Insurance' section is crucial. Provide details about your license number, accreditation type, and relevant effective and expiration dates.
9. Enter the effective date of the changes in the specified format (MM/DD/YY) in the 'Requested Effective Date of Change(s)' section. This step is required.
10. Finally, complete the 'Attestation Statement' by signing and dating the form. This section requires that an authorized representative of the agency confirms the accuracy of the provided information.
11. Once all sections are complete, save your changes. You can then download, print, or share the form through your online editor.

Get started with completing your Georgia Collaborative ASO Change Of Information Form online today!