Notification Of Change Form (Page 2 of 2) in pdf

Notification Of Change Form Page 2

Partner Network: Our Health Home partner network is changing as follows: ___________________________

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

service model.

Change in Designated Service Counties: Expansion ____ Withdrawal ____

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

service model.

For changes in Health Home name, corporate structure, or network partners, we have contacted, or will contact,

the DOH privacy officer regarding completing any amendments to our Data Exchange Application Agreements

(DEAAs).

For changes in Health Home name or network partners, we acknowledge our Consent Form (5055) must be

updated by (6 months) to reflect our new Health Home name and any changes in our network partners.

If you have any questions regarding this letter please contact _________________at telephone #_____________.

Sincerely,

____________________________________

________________

_____________________________

Signature of CEO/Executive Director

Date

Telephone #

Please return the completed and signed Notification of Change Form to:

Health Home Program

New York State Department of Health

Office of Health Insurance Programs

Division of Program Development and Management

Corning Tower, OCP-720

Albany, New York, 12237

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Notification Of Change Form Page 2