Get Primary Care Physician (pcp) Change Request Form

Filling out the Primary Care Physician Change Request Form online is a straightforward process that ensures your healthcare needs are met. This guide provides step-by-step instructions to help you navigate the form efficiently and accurately.

Follow the steps to complete the PCP Change Request Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the member information section. Enter your first name, last name, member ID number, date of birth, street address, city, state, zip code, preferred contact number, and driver license or state ID number. Make sure all details are accurate to avoid any delays.
3. Select the appropriate program by checking one of the options: Medicaid, Medicare, Children's Health Program (CHP), Qualified Health Plan (QHP), or Essential Plan.
4. In the current PCP information section, provide the current PCP name associated with your member ID, their phone number, and their Affinity ID number if known.
5. Next, proceed to the new PCP information section. Fill in the practice name, the new PCP's name, their NPI number, and Affinity ID number if known.
6. Enter the new PCP's street address, city, state, and zip code, as well as the office phone number and contact person details.
7. Indicate the reason for the change and provide the date of your last visit to the current PCP.
8. Lastly, sign and print your name on the form, along with the date of completion. Select your relationship to the member from the options provided, ensuring that you only submit one change request per form.
9. Once all fields are completed, review your entries for accuracy. Then, save your changes, and you can choose to download, print, or share the filled form.

Complete your PCP Change Request Form online today to ensure your healthcare provider is up-to-date.