Get Pcp Selection And Change Form - Coordinated Care

The PCP Selection And Change Form is essential for users seeking to select or change their primary care provider through Coordinated Care. This guide provides a detailed, step-by-step approach to help you complete the form online efficiently.

Follow the steps to fill out the PCP Selection And Change Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Once the form is open, provide your member information as required. This includes your last name, member ID, date of birth, Social Security number, telephone number, and mailing address. Ensure that all required fields are filled accurately.
3. In the PCP Change Request section, input the requested primary care provider's information. Include their NPI number, office address, city, and office phone number.
4. Select the effective date for the change. This should reflect your preferred date for the change to take place.
5. Indicate your reason for the change from your assigned PCP by selecting one or more options from the list provided. Be sure to choose at least one reason.
6. If you are the member or an authorized representative, provide your signature and the date of signing in the designated fields.
7. Finally, you can save the completed form. From this point, you can download, print, or share the document as required.

Complete your PCP Selection And Change Form online today for a seamless experience.