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 4
For assistance completing this application, please call Network Operations Department at 888-977-2160
Items 1 and 8 are required. Complete other information only if there is a change.
(Please print.)
For Eastpointe/Fiscal Agent
Use Only
Date Keyed:
1. Provider Information
Provider Name (Please use your legal name, no abbreviations)
Click here to enter text.
Medicaid Provider Number
(One provider number per form)
NPI
(One NPI per form)
Effective Date of Change
Click here to enter text.
Click here to enter text.
Click here to enter text.
Type of Provider
☐ Licensed Independent Practitioner (LIP)
☐ Hospital
☐ Agency
☐ Medicaid
☐ IPRS
2. Type of Change
Effective Date of Change: Click here to enter text.
☐ Office Site Location Change
☐ Add Site Location
☐ Closed Site Location
☐ Corporate
Contact Name
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Address (Attach copy of ne License if applicable)
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City
State
Zip Code + Plus 4 (Required)
County (Required)
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Click here to enter text.
Click here to enter text.
Click here to enter text.
Fax Number
Office/Site Phone
E-mail (Required)
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Click here to enter text.
Click here to enter text.
STR Contact
STR Phone
STR E-mail
Click here to enter text.
Click here to enter text.
Click here to enter text.
Form Revised 05/10/2013
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
☐ Mailing Address Change
Page 2 of 4
Contact Name
Click here to enter text.
Address (Attach copy of ne License if applicable)
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City
State
Zip Code + Plus 4 (Required)
County (Required)
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Fax Number
Office/Site Phone
E-mail (Required)
Click here to enter text.
Click here to enter text.
Click here to enter text.
☐ Billing Location
Contact Name
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Address
Click here to enter text.
City
Click here to enter text.
Fax Number
Click here to enter text.
State
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Billing/Mailing/Payment/
Accounting Phone
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Zip Code + Plus 4 (Required)
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E-mail (Required)
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☐ After Hours Crisis Number: Click here to enter text.
☐ NPI (Attach copy of NPPES reflecting NPI change.)
Previous NPI: Click here to enter text.
New NPI: Click here to enter text.
☐ Licensed Independent Practitioner (LIP) or Agency (Attach a copy of your new license or certification reflecting your name
change.)
Previous Full Name: Click here to enter text.
New Full Name: Click here to enter text.
☐ LIP or Agency (Attach a copy of your new license or certification reflecting your name change.)
Previous Tax Name: Click here to enter text.
New Tax Name: Click here to enter text.
☐ LIP or Agency
Previous Tax ID: Click here to enter text.
New Tax ID/SSN: Click here to enter text.
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 3 of 4
☐ Change in bed capacity from Click here to enter text. beds to Click here to enter text. beds.
(Attach state license reflecting bed capacity change.)
☐ Change in Residential Child Care Treatment Level
(Attach state license and Letter from LME/MCO reflecting treatment level change.)
☐ Change in Provider Specialty (Attach new license and letter requesting new specialty.)
☐ CLIA Certification Renewal (Attach a copy of your renewed CLIA Certificate.)
☐ DEA Certification Renewal (Attach a copy of your renewed DEA certificate.)
3. Payor Sources Accepted
Click here to enter text.
4. List of Provided Services
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5. Specialty Services
Click here to enter text.
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
6. Presenting Disability Type
Page 4 of 4
☐Adult MH
☐Adult SA
☐Child MH
☐Child SA
☐IDD
7. ☐ Hours of Operation: Click here to enter text.
8. Signature
I certify that the above 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
Phone Number
Mail this form to: Eastpointe, ATTN: Network Operations, 500 Nash Medical Arts Mall, Rocky Mount, NC 27804
Or fax to 252-407-2450.
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