Change of Provider Form.pdf

Colorado Medicaid

Change of Provider Form

This form must accompany the new Prior Authorization Request (PAR) Form when a

client has a current and active PAR with another provider.

Client Information

Client Name:

Medicaid ID#:

Date of Birth:

Current PAR Number (if known):

Previous Provider Information

Name: Last Day of Services:

New Provider Information

Name:

Provider ID#:

Client Start Date of Service:

Provider Signature:

This notice is to inform you that I,

(Client's name)

have changed providers effective:

(Date)

I am changing from provider:

(Provider's name)

to provider:

(New provider's name)

The following services/equipment will be affected by this change:

Client's Signature or (Guardian if client cannot sign) (Date)

Client's address:

(Address line 1)

(Address line 2)

(City, State and Zip Code)

Revision date: March 2015