Name/Address Change of Provider 620-01-75-01

(Revised 3/20/12 ML #3317)

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  1. The current provider who is requesting a name change must complete a new application and submit documentation verifying the name change.

 

  1. A current provider who is relocating to a new address must complete a new application, and a new licensing study or self-declaration will be completed.

 

  1. Fees and fee adjustments during a licensing, self-declaration, or registration period falls under the discretion of the authorized agent.