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  • Illinicare Change Pcp Form

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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 PC....

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You can change your doctor, for any reason, once a month. To change your doctor, call the Illinois Health Connect Helpline at 1-877-912-1999. If you use a TTY, call 1-866-565-8577. The call is free.

HealthChoice Illinois is the statewide Medicaid managed care program.

An individual must call the Client Enrollment Broker Call Center at 1-877-912-8880 (TTY: 1-866-565-8576) or go online to the Enrollment Portal at .enrollhfs.illinois.gov to get more information about their HealthChoice Illinois plan choices and to make a plan switch.

Gym Membership: IlliniCare Health will cover monthly membership fees for qualifying members age 16 and older at participating fitness centers and gyms.

IlliniCare Health's timely filing deadlines: 180 days from the date on which services or items are provided for initial and resubmitted claims. Claim disputes must be received within 180 days of the DOS or the date of discharge, whichever is later.

The Illinois Department of Healthcare and Family Services (HFS) will send letters once a year, giving those insured by Medicaid the option to change plans. This is called your annual open enrollment period.

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© Copyright 1997-2025
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3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232