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Children's Behavioral Health

CBH Provider Information Form

Contact Information

Who should we contact if we have questions about the submission:

Name:
Email:
Phone:

This form is to be used to notify CHB of additions, deletions or updates to services, or to notify us of an Agency closure.
If you are making an update, please enter all the information for the service as it was prior to the update and then select "Update"; you can then update the information which has changed.

Your Current Agency Information

Item	Current information	Updated information
Please make changes only to those items which have changed - leave items which remain the same as is.
Agency/ Organization name:		Agency/ Organization name:
EIN/Tax ID:		EIN/Tax ID:
Contract Agreement #:		Contract Agreement #:
Vendor Code #:		Vendor Code #:
NPI+3 #:		NPI+3 #:
Physical address:		Physical address:
Mailing address:	Same as physical:	Mailing address: Same as physical:
Phone number:		Phone number:
FAX:		FAX:
Website:	(enter 'None' if no website)	Website: (enter 'None' if no website)
Contact person name:		Contact person name:
Contact Person e-mail:		Contact Person e-mail:
Service provided:	Note: If you are adding multiple services, submit the form once for each service. If all the address, contact information, etc is the same for all services, simply select the new service type, and "Submit" the form again.	Service provided: If you are changing services, please "Delete" the service(s) you are no longer providing, and "Add" the new service(s).
Counties/areas served:	Counties Served Statewide Aroostook Androscoggin Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York Other:	Counties Served Statewide Aroostook Androscoggin Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York Other:
Effective date:		Effective date:
Comments
Type of submission:		If this is not a Change please select the appropriate Type of submission to the left.

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DHHS

OCFS Address

Office of
Child and Family Services
2 Anthony Avenue
Augusta, Maine 04333-011

Phone: 207- 624-7900
FAX: 207-287-5282
Crisis Hotline Services
1-888-568-1112
TTY: Maine relay 711

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