Get Primary Care Provider (pcp) Existing Patient Change Form

Filling out the Primary Care Provider (PCP) Existing Patient Change Form online is a straightforward process designed to assist users in assigning existing members to their practice. This guide provides step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the form online

1. Press the ‘Get Form’ button to access the Primary Care Provider (PCP) Existing Patient Change Form and open it in an online editor.
2. Begin by entering today’s date in the designated section. Ensure the format is consistent with the form requirements.
3. In the provider information section, fill in your practice name, tax identification number (Tax ID #), practice address, city, state, ZIP code, and practice phone number.
4. Complete the PCP-specific information, including your name and National Provider Identifier (NPI #). Also, provide the practice fax number.
5. Next, go to the existing Massachusetts member information section. Enter the member's name, member ID number, their mailing address, city, state, and ZIP code, as well as their phone number.
6. Provide the member's date of birth in the required format.
7. In the signature section, ensure that the member signs the form. If the member is under 18, a parent or legal guardian must also sign.
8. Review all filled fields for accuracy. Once verified, you can save your changes, download a copy, print the form, or share it as needed.

Begin the process of completing your documents online today!