Get Ar Dms-2609 2018-2026

The AR DMS-2609 form is essential for selecting or changing your primary care physician in the Arkansas Medicaid program. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the AR DMS-2609 form online.

1. Click the ‘Get Form’ button to access the AR DMS-2609. This will open the document in your editor for completion.
2. Begin by entering your member information. Fill in your first name, last name, middle initial, Medicaid ID number, Social Security number, and birth date in the designated fields.
3. Provide your mailing address, including the city, state, and zip code. Additionally, enter your home phone number, cell phone number, and email address for contact purposes.
4. In the Requested New Doctor section, list your preferred primary care physicians. Write the first and last names of three physicians in order of preference, along with their Medicaid Provider IDs and the date of assignment next to each.
5. Select the reasons for requesting a change of doctor by checking all applicable boxes. Be sure to choose at least one reason for your request.
6. Sign and date the form. If you are a legal guardian submitting on behalf of a minor, ensure you provide your printed name and sign in the appropriate spaces.
7. Once you have completed the form, review all entries for accuracy and save your changes. You can then download, print, or share the completed form as needed.

Complete your AR DMS-2609 form online today to ensure timely processing of your primary care physician selection.