Loading
             
                Get (pcp) Change Form - Coordinated Care Health
How it works
- 
                    Open form follow the instructions
- 
                    Easily sign the form with your finger
- 
                    Send filled & signed form or save
How to use or fill out the (PCP) Change Form - Coordinated Care Health online
Filling out the (PCP) Change Form online can be straightforward if you follow the provided instructions carefully. This guide will assist you in navigating each section of the form to ensure that your needs are appropriately addressed.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by entering your member information. Fill in the required fields, including your last name, Member ID, date of birth (in mmddyyyy format), and social security number. Ensure that the telephone number and mailing address are correctly entered, including city, state, and zip code.
- Next, move to the PCP change request section. Here, provide the sought PCP's name and office address. Make sure to fill in the city's name, office phone number, and the effective date (also in mmddyyyy format) when the change is to take effect.
- Indicate your reason for requesting a PCP change. You may select multiple options from the provided list, ensuring at least one reason is chosen. Options include issues related to location, relationship with other providers, access to care, and quality of care.
- The next part requires the signature of either the member or an authorized representative. Include the date of signing in mmddyyyy format.
- Please note, after completing the form, you can save changes, download a copy, print it, or share the filled-out form as needed.
Complete your (PCP) Change Form online now to ensure your healthcare needs are met efficiently.
Yes, your primary care physician can be transferred to a different plan using the PCP Change Form - Coordinated Care Health. This flexible option ensures that you maintain care continuity while exploring better health plan options. Make sure to review your new plan's provider network. Your health and satisfaction remain our top priorities.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
        - 
                    In businnes since 199725+ years providing professional legal documents.
- 
                    Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
- 
                    Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.