GA Collaborative Staff Update Form – February 2018
GEORGIA COLLABORATIVE ASO STAFF UPDATE FORM
(Only to be completed by approved DBHDD providers requesting a Staff Update.
This form is used to make modifications to provider information maintained by the Georgia Collaborative ASO (Collaborative) for the
Department of Behavioral Health and Developmental Disabilities (DBHDD) provider system. This form must be submitted along with the
additional documentation listed below:
Clinical Director: current resume and copy of professional license
Developmental Disabilities Director (DD): current resume and IDD Director Attestation form which can be found on the GA
Collaborative ASO website at www.georgiacollaborative.com under forms.
Developmental Disabilities Professional (DDP): current resume and IDD IDD Professional Attestation form which can be found on the
GA Collaborative ASO website at www.georgiacollaborative.com under forms.
Behavioral Support Consultant (BSC) and/or Behavioral Support Specialist (BSS): current resume, evidence of specialized
training/education and professional license/certificate
Registered Nurse (RN): copy of professional license
Chief Executive Officer: copy of Secretary of State (SOS) registration that indicates current CEO name
This form must be signed and dated by an authorized representative of the agency attesting to and authorizing the requested changes. Return
this form with any necessary attachments via e-mail to GA_enrollment@beaconhealthoptions.com
or mail to
P.O. Box 56324
Atlanta, GA 30343
Provider Information (Required)
Update Employee Information (Check the one that applies) Add Delete
(Please complete additional form if requesting both changes)
Behavioral Health Clinical
Behavioral Support Specialist
Attestation Statement (Required)
I certify that I have examined the above information and that it is true, accurate and complete. I understand that any misrepresentation
or concealment of material information may subject me to liability under civil and criminal law.
Authorized Representative’s Name (print):
Authorized Representative’s Signature: Date:
click to sign
click to edit