Get Molina Healthcare Request To Change Primary Care Provider 2017-2025

Filling out the Molina Healthcare Request To Change Primary Care Provider form online is a straightforward process that ensures your healthcare preferences are accurately updated. This guide will help you through each section of the form, making it user-friendly and easy to understand.

Follow the steps to complete your request effectively.

1. Click the ‘Get Form’ button to access the request form and open it for editing.
2. Enter the member’s name in the designated field, ensuring you provide both the first and last name. Next, input the member’s Molina ID number in the corresponding section.
3. If applicable, list additional family members who also have Molina coverage by filling out their names along with their Molina ID numbers.
4. Provide the complete address of the member, including street, city, state, and ZIP code, making sure to print the information clearly.
5. Enter the member’s phone number, followed by an optional cell or alternate phone number for further communication.
6. Identify your current Primary Care Provider by writing their name as it appears on your Molina ID card.
7. Specify the new Primary Care Provider by entering their name in the provided space.
8. Fill in the new provider’s address, including the city, state, and ZIP code. Ensure that the provider's information is printed clearly.
9. Input the new provider's phone number for direct contact.
10. Have the member or a delegated guardian sign the form in the space provided, including the name of the relationship to the member.
11. Print the first and last name of the person signing the form.
12. Enter the date on which the form is being completed.
13. After completing the form, you can save your changes, download a copy for your records, print it out, or share it as instructed.

Start completing your request online today to ensure a smooth transition to your new Primary Care Provider.