Get Mdwise Pmp Change Form

Filling out the Mdwise Pmp Change Form online can be a straightforward process if you understand each component of the form. This guide provides a clear step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Mdwise Pmp Change Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Member Hospital #' section, provide the member hospital number, applicable only for MDwise Hoosier Healthwise members. If the person is not a member, advise them to call Hoosier Healthwise at 1-800-889-9949 for assistance with the PMP change.
3. Fill out the 'Your Facility / Office' and 'Office Phone' fields with the relevant contact information of your facility.
4. In the 'Member Name' field, enter the member's first and last names to identify the individual requesting the change.
5. Enter the 'RID Number' in the specified field. Ensure that this number is active before proceeding.
6. Provide the name of the current PMP in the 'Current PMP' field to indicate which provider the change is being requested from.
7. In the 'New PMP Information' section, fill in the name of the new PMP that you wish to assign to the member.
8. For the 'Member / Legal Guardian Authorization' section, include the printed name and signature of the member or legal guardian, along with the provider number and group number.
9. Select a reason for the request to change the PMP from the options provided, such as auto-assignment, unsatisfactory quality of care, or other specific reasons. Use the space provided under 'Other' to give additional explanations if necessary.
10. Make sure the member or guardian signs and dates the signature section to authorize the change.
11. Additionally, fill out the 'Employee Name' section clearly, along with the date it is filled.
12. Once everything is filled out accurately, you can save changes, download the form, or print it for submission.
13. Finally, fax the completed form to (317) 829-5530 or 1-877-822-7190.

Start filling out the Mdwise PMP Change Form online today for a smooth provider change experience.