Get 508c, Pcp Change Form. Pcp Change Form

The 508C, PCP Change Form is a vital document for individuals seeking to change their primary care provider. This guide will provide you with clear, step-by-step instructions to help you complete the form efficiently and accurately online.

Follow the steps to fill out the 508C, PCP Change Form.

1. Press the ‘Get Form’ button to obtain the 508C, PCP Change Form and open it for editing.
2. In the 'Member Information' section, fill out the date submitted, member’s full name, date of birth, legal guardian’s name if applicable, member ID card number, address, state of residence, phone number, and include the signature of the member, parent, or guardian.
3. In the 'New PCP Information' section, indicate the effective date of the PCP change, enter the name of the new PCP, the name of the staff member processing the request, their telephone number and fax number, and provide the PCP ID number, tax ID number, and address including city and state.
4. Include the signature of the physician or representative processing the change.
5. Select the reason for the change by marking the appropriate option from the list provided.
6. If applicable, remind members to update their address with TennCare by contacting Tennessee Health Connection.
7. Once all sections are completed, review your information for accuracy, then save your changes, download, print, or share the form as needed.

Complete your 508C, PCP Change Form online today!