Corporate Office:
514 East Main Street
Post Office Box 369
Beulaville, N.C. 28518
Administration: 800-513-4002
Access to Care: 800-913-6109
Kenneth E. Jones, CEO
Eastpointe Provider Change Form
Page 1 of 6
For assistance completing this form, please call Network Operations Department at 888-977-2160
This form is used to update your information on the Provider Choice Database. (Please print)
Forms must be complete when submitted to process. (Mandatory)
1. Provider Information
CABHA AGENCY
YES
For Eastpointe/Fiscal Agent
Use Only
Date Keyed:
NO
Provider Name (Please use your legal name, no abbreviations)
Tax ID Number
Effective Date of Change
Type of Contract You Have In Place
Licensed Independent Practitioner (LIP)
2. Section A – Corporate Change
Hospital
Agency
Medicaid
IPRS
List Any Changes Below:
Physical Address
Mailing Address
County
City
State
Zip Code + Plus 4 (Required)
Office/Site Phone
Fax Number
E-mail (Required)
Contact Person
Website Address
3. Service Location Change
If More Than One Change Please Submit Additional Forms.
Contact Name
Street Address (Attach copy of new License if applicable)
City
State
Site Address or Mailing Address
Site Address
Mailing Address
Zip Code + Plus 4 (Required)
County (Required)
Why?
Fax Number
Office/Site Phone
E-mail (Required)
Form Revised 05/08/2014
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
Page 2 of 6
4. STR
STR Contact
5.
STR Phone
STR E-mail
After Hours Crisis Number/First Responder Number (one number):
6.
Counties That You Serve
County
Bladen
Columbus
Duplin
Edgecombe
Greene
Lenoir
Nash
Robeson
Sampson
Scotland
Wayne
Wilson
Other
Add
Remove
7.
Culturally Diverse Populations Your Agency Feels Competent to Treat
Population Group
American Indian/Alaska Native
Deaf/Hard of Hearing
Hispanic/Latino
Military
Muslim
White/Caucasian
Black/African American
Asian/Pacific Islander
Other:
Add
Remove
Add
Remove
8.
Languages
(are able to communicate in fluently)
Language
English
Spanish
French
Japanese
American Sign Language
German
Hmong
Portuguese
Russian
Telugd
Other:
9.
Hours of Operation:
10.
Payor Sources Accepted
Payor Source
Medicaid
Blue Cross Blue Shield
Champus/Tricare
Health Choice
IPRS/Indigent
Medicare
Self-Pay
Other Private Insurance:
Add
Remove
Add
Remove
Add
Remove
11.
Presenting Disability Type
Type
Adult Mental Health
Child Mental Health
Adult Substance Abuse
Child Substance Abuse
Adult Intellectual & Developmental Disability (IDD)
Child Intellectual & Developmental Disability (IDD)
12.
List of Provided Services (Per Your Contract)
Service
ACTT – Assertive Community Treatment Team
Assistive Technology Equipment & Supplies
Innovations
Child/Adolescent Day Treatment
Community Guide Services
Community Networking
Community Support Team
Community Transition Services
Crisis Services: Crisis Behavioral Consultation
Crisis Services: Facility Based Crisis Program
Crisis Services: Mobile Crisis
Crisis Services: Out of Home Crisis
Crisis Services: Primary Crisis Response
Day Supports
Developmental Therapy
Detoxification Services
Detoxification Services: Ambulatory
Detoxification Services: Medically Supervised or ADATC Detox/Crisis Stabilization
Detoxification Services: Non-Hospital Medical
Detoxification Services: Social Setting
Diagnostic Assessment
Home Modifications
ICF/MR
In Home Intensive Supports
In Home Skill Building
Individual Goods & Services
Inpatient Hospital Psychiatric Treatment
Intensive In-Home Services
Level II Family Type/Therapeutic Foster Care
Level II Group Type
Level III Group Home
Long Term Vocational Service
Multi-Systematic Therapy
Natural Supports Education
Outpatient for Deaf/HOH or Deaf/Blind
Outpatient Opioid Treatment
Outpatient Treatment Services
Partial Hospitalization
Peer Support Services
Personal Assistance
Personal Care
PRTF
Psychosocial Rehabilitation
Residential Supports
Residential Supports AFL
Respite
Respite: Community MH/SA
Respite: Facility
Respite: Hourly MH/SA
Respite: Nursing
Specialized Consultation Services
Substance Abuse
Substance Abuse Comprehensive Outpatient Treatment Program
Substance Abuse Halfway House
Substance Abuse Intensive Outpatient Program
Substance Abuse Medically Monitored Community Residential Treatment
Substance Abuse Non-Medical Community Residential Treatment
Supervised Living
Supported Employment
Vehicle Modifications
Other
13.
Specialty Services
Service
Add
Remove
Certified Sex Offender Specific Treatment
Chronic Pain
Eating Disorders
Forensic Screening
Services to Military Population
Trauma Focused CBT
Traumatic Brain Injury
14.
Signature
I certify that the preceding information is true and correct. I further understand that any false or misleading
information may be cause for denial or termination of participation as a Medicaid Provider. Individual provider
changes must have the provider’s signature. Authorized agents can only sign for a group change.
Signature of Individual or Authorized Agent
Date
Printed Name
Title
E-Mail Address
Phone Number
Mail this form to: Eastpointe, ATTN: Network Operations, 500 Nash Medical Arts Mall, Rocky Mount, NC 27804
Or scan and e-mail to: networkoperations@eastpointe.net
Or fax to: 252-407-2450