Get Celticare Pcp Change Request Form - Celticare Health

Filling out the CeltiCare PCP Change Request Form is an important step for users seeking to change their primary care provider. This guide will provide clear instructions to help you complete the form online efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the document and open it in your digital editor.
2. Begin by filling in your personal information. Include your full name, member ID, and date of birth in the designated fields. Make sure to provide your contact phone number as well.
3. Next, enter the requested primary care provider's information. This includes the PCP's name, provider ID, office address, city, and office phone number. Ensure accuracy to avoid any processing delays.
4. Select the effective date for your change request. This is the date you would like the transition to occur.
5. Provide a reason for the change from your assigned PCP by selecting the appropriate option. You can specify if you are already a patient with the requested PCP, if they see a family member, if distance is an issue, or any other relevant reason by checking the corresponding box.
6. Sign the form where indicated, confirming that the information provided is accurate. If an authorized representative is signing on your behalf, they should also print their name.
7. Once you have completed all sections of the form, review it for accuracy. You can then proceed to save any changes made, and choose to download, print, or share the completed form as needed.

Complete your PCP change request online today and ensure your healthcare needs are met.