MENTAL HEALTH PLAN FEE-FOR-SERVICE PROVIDER UPDATE FORM Group/ Organization Last Name First Name Name Reason for Current New Update check all that apply Change of Street City, State Street City, State Mailing Address Address & ZIP Address & ZIP Phone Fax Phone Fax Change of Billing Street City, State Street City, State Address Address & ZIP Address & ZIP Phone Fax Phone Fax Change of Tax ID Street City, State Street City, State Address Address & ZIP Address & ZIP Phone Fax Phone Fax Change of Email Current New Change of Phone Current New Number Change of Fax Current New Number Change of Name Current New Change of Tax ID Current New Number Change of status with any licensing/oversight board that may impact your ability to provide, claim, or be reimbursed for specialty mental health services Describe the change and include the licensing/oversight board Complete and submit this form to the Network Office: Alameda County Behavioral Health Care Services - Network Office 1900 Embarcadero Cove, Suite 205
MENTAL HEALTH PLAN FEE-FOR-SERVICE PROVIDER UPDATE FORM Group/ Organization Name Last Name First Name Reason for Update check all that apply Current New Change of Mailing Address Street Address City, State & ZIP Street Address City, State & ZIP Phone Fax Phone Fax Change of Billing Address Street Address City, State & ZIP Street Address City, State & ZIP Phone Fax Phone Fax Change of Tax ID Address Street Address City, State & ZIP Street Address City, State & ZIP Phone Fax Phone Fax Change of Email Current New Change of Phone Number Current New Change of Fax Number Current New Change of Name Current New Change of Tax ID Number Current New Change of status with any licensing/oversight board that may impact your ability to provide, claim, or be reimbursed for specialty mental health services Describe the change and include the licensing/oversight board Complete and submit this form to the Network Office: Alameda County Behavioral Health Care Services - Network Office 1900 Embarcadero Cove, Suite 205
PROVIDER_UPDATE.docx