Provider Change Form

Contact Information

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

Name

Phone

I am authorized to submit the website updates on behalf of the agency

Agency Information

County of Service

Type of Service

List your Evidence Based Practice(s) (EBP)

This box is required for all HCT and Outpatient providers.

Agency name

Agency Address

Agency Phone

Agency Fax

Agency Website

Contact Person

Contact Person Email

Geographical Area

Narrative

(Please be very specific about what you want to change/update):

Maine Department of Health and Human Services