Affiliate Change Form Carebridge

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Affiliate Change Form 
Please submit all changes to Carebridge EAP as soon as possible via fax at (877) 991‐5189 or email at 
.   Any questions, please contact the Provider Relations Department at (866) 993‐8477. 
Please check ONLY the boxes that apply.
SECTION I.
The primary office address has changed. PLEASE COMPLETE:  
  
 
SECTION II.
An additional office location has been added. PLEASE COMPLETE:  
  
 
SECTION III.
An office location needs to be removed. PLEASE COMPLETE:  
 
  
SECTION IV.
The office telephone, emergency, fax number, or email has changed. PLEASE COMPLETE:  
 
  
SECTION V.
Change in range of hours generally available for counseling. PLEASE COMPLETE:  
 
  
SECTION VI.
Change in insurance plans accepted. PLEASE COMPLETE:  
   
  
SECTION VII.
Change in license status. PLEASE COMPLETE:  
 
  
SECTION VIII   .
Addition of new licensing, degrees, or certifications. PLEASE COMPLETE:  
  
  
THE FOLLOWING CHANGES REQUIRE COMPLETION OF A NEW W‐9 FORM. 
SECTION IX.    
Address where payments are sent has changed.  PLEASE COMPLETE:  
 
  
THE FOLLOWING CHANGES REQUIRE COMPLETION OF A NEW W‐9 FORM AND AFFILIATE AGREEMENT
SECTION X.    
My Name and/or the name of the company/agency has changed. PLEASE COMPLETE:  
  
 
SECTION X.    
My Tax ID number (or that of the agency) has changed. PLEASE COMPLETE:  
  
 
Please provide the following information as you reported it before any changes. 
First Name: 
Middle Name: 
Last Name: 
Firm or Company Name:  
Street Address: 
City: 
State: 
Zip Code: 
Social Security/EIN #:  
Please complete ONLY the sections that apply to any changes. 
SECTION I 
NEW Primary Service Location: 
Street Address 1: 
Street Address 2: 
City: 
State: 
Zip Code:  
This office complies with federal, state/provincial, and local legal requirements 
       
  Yes 
     
 No 
governing public accessibility, health, and safety. 
This office is close to public transportation. 
       
  Yes 
     
 No 
This office is located in a home. 
       
  Yes 
     
 No 
This office is wheelchair accessible. 
       
  Yes 
     
 No 
 

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