Get Request For Changes Form - Provider Record ( Form 2

This guide provides clear and detailed instructions for filling out the Request For Changes Form - Provider Record ( Form 2 online. Whether you are making a new request or updating existing information, this comprehensive guide will assist you through each section of the form.

Follow the steps to successfully complete the Request For Changes Form - Provider Record ( Form 2.

1. Press the ‘Get Form’ button to acquire the form and open it for filling out.
2. Begin by entering the provider name in the designated field at the top of the form. This is important for accurately identifying the provider.
3. Next, enter the Medicaid site ID, NPI, and FEIN as applicable. Ensure that all identifiers are correct to avoid processing delays.
4. Indicate whether you are requesting to add a site, close a site, or change site information by checking the appropriate box.
5. Provide the effective date for the requested changes, ensuring it aligns with your operational requirements.
6. Fill out Section 2A with the primary contact person's information, including name, service addresses, and phone numbers.
7. If applicable, answer the questions in Section 2B regarding Individual Care Grant – Community Services and note any required information.
8. In Section 2C, indicate whether the location provides residential services. Include bed capacity details for adults and children as necessary.
9. Proceed to Section 2D to state whether prescriber services are available. Provide the number of hours available monthly if applicable.
10. In Section 2E, list available services your location offers. Make sure to include all relevant services.
11. Check all special populations served in Section 2F. This information is crucial for ensuring compliance with diverse needs.
12. Complete Section 2G by marking the languages spoken by direct service staff, which enhances service accessibility.
13. In Section 2H, provide your facility's hours of operation for each day of the week.
14. In Section 2I, indicate whether the facility is accessible for individuals with disabilities and if public transportation is available.
15. After filling in all relevant sections, review your entries for accuracy. Once confirmed, save the changes, download the form, or print it for submission.

Complete your Request For Changes Form - Provider Record ( Form 2 online today to ensure timely processing of your updates.