Get Tn Bluecare Primary Care Provider Change Request Form 2021-2025

Filling out the TN BlueCare Primary Care Provider Change Request Form online is a straightforward process designed to facilitate changes in your primary care provider. This guide will walk you through each section of the form to ensure you submit all necessary information correctly.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Fill in the member information section thoroughly. This includes 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 the signature of the member or guardian.
3. In the new primary care provider (PCP) information section, indicate the effective date of the PCP change, name of the new PCP, name of the staff member processing the request, as well as their telephone number, fax number, and ID and tax ID numbers for the new PCP.
4. Provide the new PCP’s address, including city and state. Ensure accurate information to avoid any processing issues.
5. Have the physician or representative sign the form in the designated section to validate the request.
6. Select a reason for the change from the provided options. This could include factors such as appointment availability or member choice.
7. Once all fields are completed, review the entire form for accuracy, then save your changes. You can also download, print, or share the completed form as needed.

Complete your TN BlueCare Primary Care Provider Change Request Form online today to ensure timely processing of your request.