EXISTING PROVIDER INFORMATION UPDATE/CHANGE FORM

INSTRUCTIONS FOR COMPLETING THE FORM

It is the County's responsibility to inform the MPF team of any changes in Contract Status (aka Facility Type code) for all subcontracted or County Operated providers - DMC & Non DMC. However, do not use this form to make identification changes (i.e. address, contacts, DBA) for a DMC CERTIFIED provider. You must contact the Provider Enrollment Division (PED) to make identification changes or updates to DMC Certified provider records. Email PED at: DHCSDMCRECERT@dhcs.ca.gov

The information furnished in this form will be used to update existing provider information in the Department of Health Care Service’s Master Provider File (MPF) database. Therefore, the integrity and accuracy of the information provided is critical.

Please READ ALL INSTRUCTIONS before filling out this form.

This is a fillable pdf form. You must have the free Adobe Acrobat Reader software downloaded to fill in the fields.

Download it here: https://get.adobe.com/reader/

Otherwise, please PRINT or TYPE all information so it is legible. You can click the PRINT button at the top of each page to print the form to fill it in by hand or use a typewriter. If filling in by hand, use only blue or black ink. Do not use pencil.

• Failure to provide complete and accurate information may cause your form(s) to be returned and delay processing.

• Please fill out one form per request type. For example, if you have multiple providers for whom you want the same service typechange made, you must fill out one form for each provider.

• Each section has REQUIRED fields. You must fill in the information in order to submit the form. If you do not, the form will not allowyou to save nor email the form.

• You can use the SUBMIT button at the top of the page to email the completed form back to the MPF team or click on a hyperlinkhere: dhcsmpf@dhcs.ca.gov

EXISTING PROVIDER INFORMATION - REQUIRED

EXISTING PROVIDER ID NUMBER: The six-digit number originally assigned to the Provider for the purpose of reporting outcomes data for treatment and/or prevention services (rendered in the service location - aka Site).

LEGAL ENTITY NAME: The corporate or administrative name. The Legal Entity should match what is on file with the Internal Revenue Service. Please ensure that spelling of name and address matches what is on file with the Internal Revenue Service.

(CalOMS stands for California Outcomes Measurement System for Treatment and Prevention

REQUEST TYPE - REQUIRED

EFFECTIVE DATE OF CHANGE: Should be entered as 2-digit day and month, and 4-digit year (xx/xx/xxxx). It should indicate the first day of the start of the changes. If terminating a contract, input the end date in this field. Changes and updates can be added retroactively.

Adding Information: Check the boxes that pertain to adding information to an existing record. If adding a new provider service location (aka Site check the appropriate box and then enter all identification information in the fields below, including the Facility Type Code (aka contract status and Service Codes – Treatment and/or Prevention.).

Changing Information: Check the box(es that pertain to changing information to an existing record, and fill in the fields for the identification changes you want made. Example: If you want to change the Legal Entity Name you will check the appropriate box and then enter the new name in the “Legal Entity Name” field.

Terminating a Provider Contract: Check the appropriate box and enter the effective end date of the contract in the effective date of change field.

PROVIDER INDENTIFICATION FIELDS

Notes: Enter any special notes and/or provider license numbers here.

Facility Director Name and Telephone Number: The name and telephone number of the medical director of the facility where the services are being provided (not the administrative or corporate address.

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EXISTING PROVIDER INFORMATION UPDATE/CHANGE FORM

Legal Entity Name: The corporate or administrative name and address of the Legal Entity should match what is on file with the Internal Revenue Service. Please ensure that spelling of name and address matches what is on file with the Internal Revenue Service.

Administrative Address: This should be the same address as filed with the Internal Revenue Service. Please ensure that spelling of address matches what is on file with the Internal Revenue Service.

Legal Entity Zip Code: A 9-digit Zip Code is required using this format 11111-1111. If you do not know the 4-digit extension for your Zip Code you can find it using the search tool at the USPS website: https://tools.usps.com/go/ZipLookupAction_input

Legal Entity Telephone Number: The corporate or administrative telephone number of the Legal Entity.

Program Contact Name and Telephone Number: The name and telephone number of the program contact of the facility where the services are being provided (not the administrative or corporate address).

Business Name and Service Location Address: The business name (dba/”doing business as”) and address of the facility where the services are being provided (not the administrative or corporate address).

Service Location Zip Code: See Legal Entity Zip Code format above.

Service Location Telephone Number: The telephone number of the facility where the services are being provided (not the administrative or corporate address).

DEFINING CONTRACT STATUS (aka FACILITY TYPE CODES)

Code 1 - County-Operated Provider: A service location that is managed by the county in which it is located. Example: County of Riverside manages multiple facilities that are directly funded with block grant monies and/or Drug Medi-Cal funding.

Code 2 - Contract with County: A county agency other than the county Alcohol and Other Drug (AOD) department operates this service location; it is contracted with the county to provide services. Example: Drug Courts and/or DUI School.

Code 3 - Provider Contracted with County: This is a service location that has directly contracted with the county to provide Substance Abuse Block Grant (SABG) funded Prevention and/or Treatment Services. Example: A non-AOD county operated service location, usually a non-profit organization within the county.

Code 7 - No SUD Funds: Used to effectively terminate a contract with a non-AOD county operated provider or when the county determines not to renew a provider contract.

Code 9 - CLOSED: Service Location no longer exists as a legal entity and therefore is no longer providing any services. NOTE: You cannot use this code if clients have not been discharge in CalOMS. You must verify beforehand that all admissions are closed for this provider before requesting the service location be assigned a code 9.

ADDING AND/OR DELETING SERVICE CODES

To make a change to the FACILITY TYPE CODE (aka contract status of the provider) use the radio buttons in the corresponding columns.

EXAMPLE: To change a Provider’s contract status from a (3) to a (7), select (7) in the ADD column and (3) in the DELETE column. To ADD and/or DELETE Treatment Services and/or Prevention Services use the check boxes in the corresponding columns.

EXAMPLE: If ADDING 30-IOT check the corresponding box in the ADD column; if DELETING 31-ODF, check the corresponding box in the DELETE column. You can add as many codes or delete as many as you need.

NOTE: To SAVE your edits to your desktop, go to the "File" drop down menu at the top left corner of the document, then scroll down to "Save as" and label the form with the following convention: COUNTY NAME_DATE (XXXXXXXX). Then select the folder you want to save the document to and click the "Save" button.

If you make an incorrect selection in any of the radio buttons or check boxes you can use the keyboard short cut to undo the last 10 entries on the form. Hold down the CTRL key plus the Z key on your keyboard to UNDO the incorrect selections, then re-select the correct options. If you need to start the entire form over, simply click the RESET button at the top of the page.

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EXISTING PROVIDER INFORMATION UPDATE/CHANGE FORMPLEASE READ THE INSTRUCTIONS PROVIDED BELOW BEFORE FILLING OUT THIS FORMThis form requires the free Adobe Acrobat Reader software.Download it here: https://get.adobe.com/reader/

Requester Information - Required County Name

Submitted by

Phone Number

MPF Analyst Information (MPF Staff Use Only)

Request Completed By

Date Request Completed

Provider Information - Required

Existing Provider ID Number

Legal Entity Name

Request Type (Choose All That Apply) - Required

Effective Date of Change

Contract Status Change (aka Facility Type)Add/Delete Treatment and/or Prevention Service Codes Add a New Service Location to an Existing Legal Entity Record Make Legal Entity or DBA Name Change Make Address Change (Admin and/or Service Location) Make Phone Number Change (Admin and/or Service Location)

NOTES:

Director Name and/or Phone Number

Legal Entity Name

Administrative Address

City State Zip Code

Administrative Phone Number

Program Contact Name and/or Phone Number

Business Name (DBA/Doing Business As)

Service Location Address (Mailing/Site)

City State Zip Code

Service Location Phone Number (Mailing/Site)

READ BEFORE COMPLETING THIS SECTION: The boxes below can be used to add or delete codes for a Prevention or Treatment Provider. EXAMPLE: If changing a Provider’s Facilty Type Code from a (3) to a (7), you would check ADD for (7) and DELETE for (3). If ADDING or DELETING Treatment/Prevention Codes, simply check all that apply in the corresponding columns below.

Facility Type Code

Add Delete

1 - County Operated Provider

2 - Contract w/ County (County Agency)

3 - Provider Contracted w/ County

7 - No SUD Funds (No Longer Contracted)

9 - Closed for Business (No Longer Exists)

Treatment Service Code

Add Delete

30 - Intensive Outpatient Treatment (IOT)

31 - Outpatient Drug-Free (ODF)

40 - Narcotic Treatment Program (NTP)

43 - Naltrexone Treatment (NAL)

51 - Residential - 31 days or more (RES)

52 - Residential - 30 days or less (RES)

Prevention Service Code

Add Delete

12 - Information Dissemination

13 - Education

14 - Alternative

15 - Problem ID and Referral

16 - Community Based Process

17 - Environmental