Provider Change Request

Request to Change Service Provider

Transfer Policy

You may request to transfer therapists/providers or outpatient locations.
To do so, complete this change of service provider form and return it to the front desk. A supervisor will review the request.
You will then be contacted to inform you of the decision and if approved, scheduled with the new therapist or prescriber.

Please contact the outpatient manager at 863.519.0575 Ext. 6694 or by email if you are having trouble accessing the form.

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