Get Member Assignment Request

Filling out the Member Assignment Request is a straightforward process that enables users to request a change in their primary care provider. This guide provides step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to successfully fill out the Member Assignment Request form.

1. Select the ‘Get Form’ button to access the online form and open it in your browser.
2. Enter the date in the designated field to indicate when the request is being submitted.
3. Fill in the Member Name field with the full name of the person requesting the change.
4. Input the Member Medicaid ID number in the provided space; ensure this number is accurate to avoid processing delays.
5. Check the boxes under 'Meridian Member Authorization' to confirm that either the member, parent, or guardian is providing the necessary consent for the primary care provider change.
6. Sign the form in the designated area to authorize the request. If applicable, have the parent or guardian sign if the member is a minor or unable to sign themselves.
7. Review all information for accuracy before proceeding; make any necessary corrections to prevent issues with processing.
8. Once completed, users can save changes to the form, download it, print a copy, or share it as required.

Complete your Member Assignment Request online today!