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Exhibit M - Attachment II

CHANGE OF INFORMATION FORM

DATE:

TO:

Provider Relations FAX: (626) 299-7251

FROM:

(Print or Type)

FACILITY NAME:

Telephone #:

Healthy Families T h e f o l l o w i n g i n f o r m a t i o n w i l l c h a n g e , e f f e c t i v e IHSS - No. of Medical Group Affiliations:

Medi-Cal/Temps No. of Sites:

Clinic Site Status:

Federally Qualified Health Center (FQHC)

Community Clinic (CC)

(If Applicable)

DHS Facility (DHS)

Primary Care Clinic (PCC)

Rural Health Clinic (RHC)

Provider Deleted (retired, no longer with IPA, etc) Provider Name:

Provider ID # Credentialing/Recredentialing Date: Transfer members to:

(Provider Name)

Provider ID #:

Credentialing Date:

Address:

Clinic Status of New Site:

Provider Business Name Address Other: (i.e., CHDP/CPSP Status)

Appointment Telephone Number Member Services Phone # Office Hours

Change From: Change To:

The above changes have been requested and authorized by:

Contract Liaison/DHS Facility Liaison’s Signature CHP OFFICE USE ONLY

Date

Date:

Initials:

Change of Information Form

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