Get Provider Primary Care Provider Selection Form - Unicare

Completing the Provider Primary Care Provider Selection Form for UniCare is an essential step in choosing your primary care provider. This guide will provide you with clear, step-by-step instructions on how to accurately fill out this online form.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in your selected editor.
2. In the member section, provide your first and last name, along with your membership ID number. This information is crucial for identification purposes.
3. Next, list your first choice and second choice for a primary care physician (PCP), including their first and last name.
4. For each family member, enter their name and specify their first and second choices for a PCP. Remember, family members can choose the same or different PCPs.
5. Fill in your contact details, including your street address, city, state, and ZIP code. Also, provide a daytime phone number where you can be reached.
6. At the bottom of the form, print your name and provide your signature. This step confirms your request for a PCP change.
7. Once the form is completed, review all entered information for accuracy. After confirming that everything is correct, save the changes.
8. You can then download, print, or share the completed form as needed. Ensure that it is submitted to your PCP’s office or faxed to UniCare at the number provided.

Take the next step and complete your Provider Primary Care Provider Selection Form online today.