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Get Molina Healthcare Request To Change Primary Care Provider 2017-2025
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How to fill out the Molina Healthcare Request To Change Primary Care Provider online
Filling out the Molina Healthcare Request To Change Primary Care Provider form online is a straightforward process. This guide will assist you step-by-step in completing the form accurately and efficiently.
Follow the steps to complete your request smoothly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the member’s name. Print both the first and last name clearly in the designated area.
- Next, enter the member’s Molina ID number in the specified space.
- Provide the member’s address, including the city, state, and ZIP code. Ensure all information is printed clearly.
- Fill in the member’s phone number and, if applicable, the cell or alternative phone number.
- Indicate the current primary care provider listed on your Molina ID card.
- Specify the name of the new primary care provider. Be sure to print their name clearly.
- Enter the new provider’s address, including city, state, and ZIP code, in the appropriate fields.
- Provide the new provider’s phone number.
- At the end of the form, the member or an authorized guardian should sign, indicating their consent, and print their name. Include the date of the request.
- After completing the form, you can save any changes, download it for records, print it out, or share it as needed.
Submit your completed form online to ensure your primary care provider change is processed promptly.
To join the Molina provider network, you, the group practice or organization must first be contracted with Molina. Prior to contract execution, we ensure all practitioners and organizations meet specific credentialing criteria and are approved by Molina's Regional Network and Credentialing Committee (RNCC).
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