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  • Primary Care Provider Change Request Form

Get Primary Care Provider Change Request Form

BlueCare TennCareSelect SM Primary Care Provider Change Request Form Member Information: Please complete and fax to: 18882619025 Member ID Date of birth (month/day/year) Member Name: First MI Last.

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How to fill out the Primary Care Provider Change Request Form online

This guide provides clear instructions on how to fill out the Primary Care Provider Change Request Form online. Whether you are changing your primary care provider for the first time or updating your information, this comprehensive guide will assist you in each step of the process.

Follow the steps to successfully complete the form.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin by entering your member information. Fill in your member ID, date of birth in the specified format (month/day/year), and your full name. Ensure accuracy to avoid processing delays.
  3. Provide your current address, including city, state, and ZIP code. Include a reachable phone number for any follow-up communication.
  4. In the provider information section, enter the name of your new primary care provider (PCP) along with their provider number. This information is necessary for your health plan to update your records.
  5. Fill out the new PCP's address, including city, state, and ZIP code, as well as their phone number, fax number, and email address, if available.
  6. Next, ensure the new PCP's signature is recorded, along with the date and their NPI number (National Provider Identifier). This step confirms that the new provider is aware of the change.
  7. Indicate the reason for the change by selecting one of the options available. If applicable, provide a brief explanation for 'Other'.
  8. If you or the member are in custody of the Department of Children’s Services (DCS), remember that a signed form from a DCS representative is required for the change to be processed.
  9. Once all sections are complete, review your entries for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Primary Care Provider Change Request Form online today!

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Members can also change a PCP over the phone by calling 1-888-FIDELIS (1-888-343-3547). PCP Change Effective Date: Typically the 1st of the month when the form is received by Fidelis Care.

Check the member's ID card and logon to our provider portal, Provider Access Online, to verify current eligibility and coverage details: https://providers.fideliscare.org Contact the Fidelis Care Provider Call Center and use the automated eligibility tool at 1-888-FIDELIS (1-888-343- 3547), option 2, then option 1.

To change your health plan, contact the NC Medicaid Enrollment Broker. To change your assigned primary care provider listed on your insurance card, contact your health plan.

If you are currently submitting more than 200 claims per month to Fidelis Care, please contact us at 1-888-FIDELIS to learn more about your electronic claim submission options. IMPORTANT – Claims must be submitted within 90 (ninety) days from the date of service.

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Fill Primary Care Provider Change Request Form

Use this form to let us know that you are changing your Primary Care Provider (PCP). You must complete each section of the form. Please complete this form with your provider if you want to change your PCP. If you'd like to change your. PCP or your child's PCP, bring this form to the provider you wish to be your PCP or your child's PCP to complete. Lexington, KY 40512-4168. If you want to ask for a new PCP who works with your plan, fill out this form and fax it to 1-. Please allow 24 to 72 hours for processing. Complete this form to change your PCP. Please complete only one form per member household.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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 WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
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