Get Pca-1-004401 Ma Pcp Change Request Form R1 011717.indd

This guide provides clear and detailed instructions for filling out the PCA-1-004401 MA PCP Change Request Form online. By following these steps, users will be able to smoothly navigate the form and submit their request for a primary care provider change.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the ‘Member Statement’ section, indicating that you wish to change your primary care provider to the specified doctor. Include their first and last name, as well as the group practice name if applicable.
3. Complete the ‘Member Information’ section by filling in your last name, middle name, first name, street address, city, state, ZIP code, phone number, date of birth, and member ID number.
4. In the ‘Provider Information’ section, fill in the name of your previous primary care provider and your new primary care provider. Provide the new provider's UnitedHealthcare ID number, as well as their address, consisting of street, city, state, and ZIP code.
5. Specify the reason for changing your primary care provider in the corresponding section, ensuring to provide a clear and concise explanation.
6. Make sure to sign the form in the ‘Member Signature’ section and include the date of signing.
7. After filling out the entire form, review all entries for accuracy. You can then save any changes made, download a copy for your records, and print the form if necessary.
8. Finally, fax the completed form to UnitedHealthcare Member Services at 844-881-4857.

Take the first step towards your new primary care provider by completing the PCA-1-004401 MA PCP Change Request Form online today.