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