Get Primary Care Provider Selection Form For Hmsa Members (1/1/17)

This guide provides detailed instructions on completing the Primary Care Provider Selection Form for HMSA members online. Following these steps will help you select or confirm your primary care provider effectively and efficiently.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to obtain the Primary Care Provider Selection Form and open it in your document editor.
2. Begin by checking the applicable HMSA plan by selecting one of the following options: HMSA HMO, QUEST Integration, HMSA Akamai Advantage, or HMSA PPO.
3. In the section labeled ‘PCP Selection for Self’, write your full name in the designated space, followed by your chosen primary care provider's full name.
4. If you are selecting a primary care provider for a child under 18 years old, complete the section titled ‘PCP Selection for Child under 18 Years Old’ with the HMSA subscriber or authorized representative’s full name, the child’s full name, and the provider’s full name.
5. Continue by entering the patient’s full name as it appears on their HMSA Membership Card and their date of birth.
6. If the patient is not the subscriber, input the subscriber's name and HMSA subscriber ID.
7. Complete the patient’s address and phone numbers, including daytime and evening contact information.
8. In the Patient Attestation section, review the statements and understand the responsibilities relating to choosing a primary care provider within HMSA's network.
9. Finally, sign and date the form. If you are the subscriber, ensure that your signature is included; otherwise, the authorized representative must sign.
10. After completing all sections, save your changes. You can download, print, or share the form as needed.

Complete your Primary Care Provider Selection Form online today for a seamless healthcare experience.