Get Illinicare Change Pcp Form

PCP Change Request Form MEMBER INFO First/MI/Last Address City Zip DOB SSN Member ID Phone PCP CHANGE REQUEST Requested PCP Name Provider ID Office Address Office Phone Effective Date REASON FOR CHANGE FROM ASSIGNED PCP Already patient with requested PCP Member Preference Member Moved PCP Hours didn t fit member need Quality of Care Provider Location Association with hospital or medical group Signature of Member or Authorized Representative Language/communication barriers Wait time in provider office Availability to get appointment. Access to care Established relationship w/ another Other 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 855-254-1790 or mail it to IlliniCare Member Services 999 Oakmont Plaza Drive Westmont IL 60559. PCP Change Request Form MEMBER INFO First/MI/Last Address City Zip DOB SSN Member ID Phone PCP CHANGE REQUEST Requested PCP Name Provider ID Office Address Office Phone Effective Date REASON FOR CHANGE FROM ASSIGNED PCP Already patient with requested PCP Member Preference Member Moved PCP Hours didn t fit member need Quality of Care Provider Location Association with hospital or medical group Signature of Member or Authorized Representative Language/communication barriers Wait time in provider office Availability to get appointment. Access to care Established relationship w/ another Other 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 855-254-1790 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 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 855-254-1790 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.