Notification Of Change Form printable pdf download

Notification Of Change Form

Notification of Change Form

[Health Home Name and Address]

Date: [Date]

NPI#: [NPI]

Provider MMIS#: [MMIS#]

This Notification of Change Form is used to inform the NYS Department of Health of any changes made to your

Health Home from your originally approved Health Home application and designation letter. Please check all that

apply:

Changing Designated Corporate Name:

o Our current Health Home name as listed on our application is: ________________________________

o The new name is: ___________________________________________________________________

We are not changing our NPI number, but changing our name by doing business as (DBA):

o The new name is: ___________________________________________________________________.

Applying for a new NPI number: (https://nppes.cms.hhs.gov/NPPES/Welcome.do)

o Our current NPI# is: ______________. The new NPI# is: _______________. (NPI# is pending ___ )

Additional Requirements: A Certificate of Assumed Name may be required by your Health Home organization.

Further instructions on required documents can be found on the Department of State’s website at:

Lead Health Homes that hold certifications as clinics or hospital-based

providers under Article(s) 28, 31 and/or 32 that change their name and/or apply for new NPI#s after receipt of

their NYS Approved Health Home Letter, are requested to contact respective agency staff for any additional

guidance. Contact information regarding Article(s) 28, 31 and 32 is located on the Health Home website at:

led_hh_rev.htm

Change in Health Home Corporate Structure: Merger ___ Separate ____Other_____________

o Attach a detailed description of the changes and indicate how they will impact your Health Home

service model

Change in Care Management Tool:

____________________________________________________________

Billing Agent: We will remain the lead Health Home, but will be using a new billing agent whose name

is_____________________________________, NPI# ____________________.

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Notification Of Change Form