Get Pcp Request For Transfer Of Member - Wellcare

Filling out the PCP REQUEST FOR TRANSFER OF MEMBER form is essential for facilitating the transfer of care for members in need. This guide will provide you with clear, step-by-step instructions to complete the form accurately and efficiently online.

Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's medical record number in the corresponding field labeled 'Med Rec #'.
3. Complete the 'Physician' field with the name of the physician making the transfer request.
4. Fill in the 'Member' field with the full name of the member who is being transferred.
5. Provide the member's ID number in the first 'ID#' field. Ensure this number is accurate.
6. If applicable, enter the member’s additional ID number in the second 'ID#' field.
7. In the 'Telephone' field, input the primary contact number for both the physician and the member.
8. Complete the 'Fax' field should you wish to receive any correspondence via fax.
9. Select the relevant insurance type by checking the appropriate box for Commercial, Medicare, or Medicaid.
10. In the section labeled 'Please include a detailed reason for request', choose the applicable option(s) that describe the reason for the transfer.
11. For missed appointments, fill out the specific dates in the designated fields.
12. If there are other reasons, provide a detailed description in the 'Other' field.
13. Attach a copy of the progress notes from the member’s medical record that supports the transfer request.
14. Sign and date the form in the 'Physician signature' and 'Date' fields respectively.
15. Review the completed form for accuracy and completeness.
16. Submit the request to the specified address or fax number provided in the instructions.
17. Upon submission, you can save changes, download a copy for your records, or print the form if needed.

Complete your PCP REQUEST FOR TRANSFER OF MEMBER form online today to ensure a smooth transition for your member's care.