Client Change of Provider Request
If you would like to change the provider receiving Foundation funding on your behalf, complete this form. Funding cannot transfer to a new provider automatically — the new provider must be an enrolled Paperflower Foundation partner. Contact us if you need help finding a partner provider in your area.
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Provider Name
*
Last Date of Service with Current Provider
*
-
Month
-
Day
Year
Date
Reason for change (optional — you are not required to explain)
Moving to a new location
Provider is no longer available
Seeking a different type of service
Personal preference
Concern about current provider
Concern about current provider - I would also like to file a grievance
Other
Requested New Provider Name (if known)
*
Is this provider a Paperflower Foundation partner?
*
Yes
No
No — I would like the Foundation to help me find a partner provider
I am not sure
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: