Get Pcp Form

Filling out the Primary Care Physician (PCP) Change Request Form online can help streamline the process of updating your healthcare provider details. This guide will provide you with clear, step-by-step instructions to ensure your form is completed accurately and efficiently.

Follow the steps to successfully complete the Pcp Form online.

1. Press the ‘Get Form’ button to download the PCP Change Request Form and open it in your preferred online editor.
2. Enter your member information in the designated fields. This includes your first name, last name, member ID number, date of birth, street address, preferred contact number, city, state, zip code, and driver's license or state ID number.
3. Indicate whether you would like to be contacted by selecting 'Yes' or 'No'. Choose the appropriate program from the options provided: Medicaid, Medicare, CHP, QHP, Essential Plan, or HARP.
4. Provide your email address for any follow-up communications.
5. Fill in the current PCP information if available, including your current PCP on member ID, their phone number, and affinity ID number if known. If you have never visited the PCP, indicate this by checking the provided box.
6. Enter the new PCP information. This should include the group name if any, NPI number, street address, phone number, name of the new PCP, affinity ID number, and city, state, and zip code of the new PCP.
7. Designate a contact person for the new PCP if applicable and provide the reason for the change in the specified area.
8. Complete the form by entering your name where it states 'Form completed by,' along with your contact number.
9. Authorize the changes by signing and dating the form where indicated. Specify your relationship to the member, choosing from the provided options.
10. Finally, save your changes, download a copy of the completed form, or print it for submission. Remember, only one change request can be submitted per form; plan accordingly for any additional requests.

Take action now and complete your PCP Change Request Form online to ensure seamless healthcare support.