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  • Primary Care Provider Change Request Form

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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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Related content

[PDF] HPM 589A4-359 Patient Request to Change...
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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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© 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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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 workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
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