Affiliate Change Form Carebridge Page 2
Download a blank fillable Affiliate Change Form Carebridge in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Affiliate Change Form Carebridge with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4SECTION II
NEW Secondary/Additional Location:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
This office complies with federal, state/provincial, and local legal requirements
governing public accessibility, health, and safety.
Yes
No
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
SECTION III
REMOVE Office Location:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
SECTION IV
CHANGE to Office Telephone, Emergency, Fax Number, or Email
Secure Primary Phone #: 24/7 Access #: Secure Alt Phone #:
Secure Email:
Secure Primary Fax #:
SECTION V
CHANGE to Normal Office Hours
General range of
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
From
To
From
To
From
To
From
To
From
To
From
To
From
To
hours you are, or
can be, available
.
SECTION VI
CHANGE in Insurance Plan Information
Please note which insurance plans you currently accept:
Aetna
Cigna
Magellan
Personal Choice
Value Options
Amerihealth
Corphealth
Medicaid
PHCS
Wellpoint
Anthem
Coventry
Medicare
Qualcare
Other: _________________________
APS
First Health
MHN
Tricare
Other: _________________________
Beechstreet
Great West
Optum
UBH
Other: _________________________
Blue Cross
Humana
Oxford
UHC
Other: _________________________
Blue Shield
Kaiser
PacifiCare
Univera
Other: _________________________
SECTION VII
CHANGE in License Status
Original License Class (license MUST be for independent practice):
MFT
PC
SW
Psychologist
MHC
Please provide a description of the change in license status:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal