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Get Illinicare Change Pcp Form

IlliniCare PCP Change Request Form Member Information First Name Last Name M. I. Member ID SSN DOB Address Phone Number PCP Change Request Please Provide PCP Information Requested PCP Name Provider ID Office Address City Zip Code Office Phone Effective Date Reason for Change from Assigned PCP Already patient with requested PCP Requested PCP already sees family member Member Preference Member Moved PCP Hours didn t fit member need Quality of Care Association with hospital or medical group Language/communication barriers Wait time in provider office Availability to get appointment. Access to care Established relationship w/ another Other Provider Location Signature of Member or Authorized Representative Date Printed Name of Authorized Representative Directions Please fax Member Change Data forms with a copy of the member ID card if available to IlliniCare Member Services Department at 855254-1790 or mail it to IlliniCare Member Services 999 Oakmont Plaza Drive Westmont IL 60559. If you have questions about how to complete this form please call the IlliniCare Member Services Department Monday through Friday 8 a*m*-5 p*m* at 866 329-4701 TDD/TTY 866 811-2452. Access to care Established relationship w/ another Other Provider Location Signature of Member or Authorized Representative Date Printed Name of Authorized Representative Directions Please fax Member Change Data forms with a copy of the member ID card if available to IlliniCare Member Services Department at 855254-1790 or mail it to IlliniCare Member Services 999 Oakmont Plaza Drive Westmont IL 60559. If you have questions about how to complete this form please call the IlliniCare Member Services Department Monday through Friday 8 a*m*-5 p*m* at 866 329-4701 TDD/TTY 866 811-2452.

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