Agency Change Form
Bureau of Long Term Care
Participant
Medicaid #
Name
Date
Region
Regional
(208)
Fax#
Current
Agency
Agency
Agency
Contact
Phone#
New
Agency
Agency
Agency
Contact
Phone#
Reason for
Change
If Agency
(Please provide information and a Nurse Reviewer will contact the participant.)
Change is
due to an
issue or
complaint
th
Agency Change requests received by the 25
of the month are effective the first day of the following month. Requests
th
received after the 25
will not be effective until the first day of the second month.
Case by case exceptions for changes during the month will be considered by the Department for Instances of Fraud or
Abuse by the caregiver, please provide information above.
Participant
Date
Signature
After form is complete, please send form to:
Email (Click Region Below):
Region1
–
Region2
–
Region3
–
Region4
–
Region5
–
Region6
–
Region7
Fax:
Region1 (208)666-6856 - Region2 (208)799-5167 - Region3 (208)454-7625 - Region4 (208)334-0953 - Region5 (208)736-2116 - Regions6 (208)239-6269 - Region7 (208)528-5756
BLTC Agency Change V1.2
Page 1 of 1
08/2017
Agency Change Form
Bureau of Long Term Care
Participant
Medicaid #
Name
Date
Region
Regional
(208)
Fax#
Current
Agency
Agency
Agency
Contact
Phone#
New
Agency
Agency
Agency
Contact
Phone#
Reason for
Change
If Agency
(Please provide information and a Nurse Reviewer will contact the participant.)
Change is
due to an
issue or
complaint
th
Agency Change requests received by the 25
of the month are effective the first day of the following month. Requests
th
received after the 25
will not be effective until the first day of the second month.
Case by case exceptions for changes during the month will be considered by the Department for Instances of Fraud or
Abuse by the caregiver, please provide information above.
Participant
Date
Signature
After form is complete, please send form to:
Email (Click Region Below):
Region1
–
Region2
–
Region3
–
Region4
–
Region5
–
Region6
–
Region7
Fax:
Region1 (208)666-6856 - Region2 (208)799-5167 - Region3 (208)454-7625 - Region4 (208)334-0953 - Region5 (208)736-2116 - Regions6 (208)239-6269 - Region7 (208)528-5756
BLTC Agency Change V1.2
Page 1 of 1
08/2017
