Network Change Request Form

* Required Information

Provider Relations checks for NCR submissions daily on weekdays. Form requests submitted on weekdays prior to 4 p.m. will be acknowledged within 24 hours of receipt. Forms submitted outside those hours will be addressed on the next business day.

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* 1. Briefly describe what is needed:

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* 2. Legal Entity (LE) Name: ie. Pacific Clinics, Momentum for Health, County of Santa Clara

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* 3. Date of request:

Date / Time

Date

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* 4. Contact Person:

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* 5. Contact role:

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* 6. Contact phone:

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* 7. Contact E-mail:

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* 8. Network Adequacy Change Notification: (Choose only 1 per form)

New Legal Entity (LE) Name (Provider Notification)

New CCP E-mail/website (Provider Notification)

New CEO/CFO/Key Contact Change/Ownership % (Provider Notification)

New Head of Service (HOS) Information (Provider Notification)

New Reporting Medical Director (Provider Notification)

New hours of Operations (by location) (Provider Notification)

New location/ New Program (Site Certification, 274 and Electronic Health Records)

Medi-Cal Claims Location Closure (Site Certification, 274 and Electronic Health Records)

Mental Health add/change modes of service (Site Certification, 274 and Electronic Health Records)

Partial move (Site Certification, 274 and Electronic Health Records)

Renovation (Site Certification, 274 and Electronic Health Records)

Temporary Closure (Pause referrals) (Network Adequacy Notification)

Program Closure (Permanent closure only) (Network Adequacy Notification)

Legal Entity Closure (Network Adequacy Notification)

Cancel request/ Submitted an error. (use question 1 to explain error)