Change in Approved Provider Unit



163830-20002500APPROVED PROVIDER CHANGE NOTIFICATION FORM V1.2020The Primary Nurse Planner must notify the Midwest Multistate Division CE Program of any changes occurring within the Approved Provider Unit/Organization that alter the information submitted in the Approved Provider application, in writing, within 30 days of the discovery or occurrence. Return completed form to Midwest MSD office at sara@. Approved Provider Unit:Primary Nurse Planner Name & Credentials:Address:City:State:Zip Code:Phone:Preferred Email:Date Change Effective:This Information is Being Provided by:Insert name and titlePhone:Preferred Email:Please check the type of change occurring and describe and/or provide the new information below:?Change in Primary Nurse Planner – Submit completed Nurse Planner Biographical Data Form(s) for reviewPrimary Nurse Planner Name: FORMTEXT ?????Nurse Planner Biographical Data form attached?Attestation: Part 1 of the PNP Orientation Checklist has been completed?Change in Nurse Planner(s) – Submit completed Nurse Planner Biographical Data Form(s) for reviewNurse Planner Name(s): FORMTEXT ?????Nurse Planner Biographical Data form attached?Change in address: Old Address: FORMTEXT ????New address: FORMTEXT ?????Change in Approved Provider Unit/Organization name: Old name: FORMTEXT ????New name: FORMTEXT ?????Change in ownership/merger that may or may not directly impact the Approved Provider UnitExplanation of change in ownership/merger, including the effective date: FORMTEXT ????? Organization chart attached?Significant changes or events that impair your ability to meet or continue to meet ANCC/Midwest MSD accreditation requirements or that make you ineligible for Approved Provider status?Suspension, lapse, revocation, or termination of the PNPs or NPs registered nursing license?Indication of potential instability (e.g. labor strike, reduction in force, bankruptcy) that may impact the organization’s ability to function as an Approved ProviderExplanation of the event and effective date: FORMTEXT ?????Any event that might result in adverse media coverage related to the delivery of CNEExplanation of the event and date of occurrence: FORMTEXT ?????Change in commercial interest status (i.e. if the Provider Unit becomes part of an organization that is considered a commercial interest.)?A decision not to submit approved provider application after intent-to-apply form has been submitted?Other – (Describe): FORMTEXT ????-6477110287000Midwest Multistate Division ● 3340 American Ave, Suite F ● Jefferson City, MO 65109Voice: 573-636-4623 ● ................
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