Fillable Form 6.: GEORGIA COLLABORATIVE ASO STAFF UPDATE FORM

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Form 6.: GEORGIA COLLABORATIVE ASO STAFF UPDATE FORM

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GA Collaborative Staff Update Form – February 2018
Page 1 of 1
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:
1.
Clinical Director: current resume and copy of professional license
2.
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.
3.
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.
4.
Behavioral Support Consultant (BSC) and/or Behavioral Support Specialist (BSS): current resume, evidence of specialized
training/education and professional license/certificate
5.
Registered Nurse (RN): copy of professional license
6.
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
GA
Collaborative Enrollment
P.O. Box 56324
Atlanta, GA 30343
Provider Information (Required)
Agency Name:
Taxpayer ID#:
Address:
Update Employee Information (Check the one that applies) Add Delete
(Please complete additional form if requesting both changes)
☐
Chief Executive Officer
☐
Georgia Owner
☐
☐
Site Contact Person
☐
Behavioral Health Clinical
Director
☐
Developmental Disabilities
Director
☐
☐
Developmental Disabilities
Agency Nurse
☐
Agency Contact Person
☐
Behavioral Support
Consultant
☐
Behavioral Support Specialist
New Name:
Phone Number:
Email Address:
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):
Title:
Authorized Representative’s Signature: Date:
Phone Number:
Email Address:
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Form 6.: GEORGIA COLLABORATIVE ASO STAFF UPDATE FORM

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Completed 9 April 2021

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