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APD Provider Clearinghouse Information Update Notification

INSTRUCTIONS: The following form should be completed and submitted upon any changes to your Clearinghouse contact information. As stated below, this does NOT update your AHCA portal account, thus you will need to log into your AHCA portal account and edit your account profile in order for the changes to be reflected within that system. This form should also be submitted when requesting the termination of Clearinghouse access for an administrator who is no longer with your business or is no longer operating as your business’ background screening agent. Please be sure to complete the form in its entirety and provide a brief description of what changes/updates are needed in the notes section provided.

IMPORTANT: This form is NOT to update your AHCA Portal Account, please log in to the Clearinghouse to update your account information.

This form is for current APD Providers who have submitted a Notice of Intent and have an update to their information.

Please ensure your information is kept up to date!

Required Information* (this is as listed in the Clearinghouse, see example)

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