Change of Provider

* Form must be completed in its entirety or will not be accepted

Member Name *

Member ID # *

Service Being Rendered: *

I (print name of member/parent/legal guardian), *

hereby wish to change the above listed services being provided by (print name of previous provider) *

to (print name of new provider) _Fundamental Therapy Solutions

Effective

(date the change is to take place).

Signature of Member of Parent/Legal Guardian if a minor

Clear

Date Signed by Member/Parent/Legal Guardian

Relationship to Member

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