Get Change Pcp Request Form - Uhccommunityplan.com

Filling out the Change PCP Request Form is an essential process for members wishing to change their primary care physician. This guide will provide you with clear, step-by-step instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to complete the Change PCP Request Form online.

1. Press the ‘Get Form’ button to access the Change PCP Request Form and open it in your editing interface.
2. Enter the date of your request in the designated field at the top of the form, using the format month/day/year.
3. Fill out the member information section by entering the member's full name, member ID number, date of birth, and address, including city, state, and zip code.
4. Have the member sign and date the form in the member signature section.
5. In the care provider information section, indicate whether your provider panel is open to new TennCare patients by selecting 'Yes' or 'No.'
6. If the provider panel is closed, provide a reason for adding the patient to the closed panel in the appropriate space.
7. Enter the new primary care provider's name, NPI number, tax ID, and TIN. Include the PCP office address with city, state, and zip code.
8. Provide the phone and fax numbers for the new PCP's office.
9. Ensure the provider or designee signs and dates the form in the designated signature section.
10. After completing the form, fax it to the number 888-205-9851. Keep a copy for your records.
11. To finalize, check if you need to contact United Healthcare Member Services for any inquiries related to the request.

Complete the Change PCP Request Form online now to ensure timely processing of the request.