Molina Healthcare Request to Change Primary Care Provider free printable template

Request to Change Primary Care Provider Members Name: Members Molina ID #: Please print FIRST and LAST name. Additional Family Molina Members Name: Members Molina ID #: Members Name: Members Molina

How to fill out Molina Healthcare Request to Change Primary Care

How to fill out Molina Healthcare Request to Change Primary Care Provider

1. Obtain the Molina Healthcare Request to Change Primary Care Provider form from the Molina Healthcare website or your local office.
2. Fill in your personal information, including name, date of birth, and member ID number.
3. Specify your current primary care provider's name and contact information.
4. Provide the name and contact information of the new primary care provider you wish to switch to.
5. Indicate the reason for the change, if applicable.
6. Sign and date the form to confirm the request.
7. Submit the completed form via fax, mail, or in-person as directed on the form.

Who needs Molina Healthcare Request to Change Primary Care Provider?

1. Members of Molina Healthcare who wish to change their primary care provider.
2. Individuals who have had a change in their healthcare needs or preferences.
3. Patients seeking specialized services not available with their current provider.
4. Those dissatisfied with their current primary care provider.

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What is Molina Healthcare Request to Change Primary Care Provider?

Molina Healthcare Request to Change Primary Care Provider is a formal process that allows members to request a change in their designated primary care provider within the Molina Healthcare network.

Who is required to file Molina Healthcare Request to Change Primary Care Provider?

Members of Molina Healthcare who wish to change their primary care provider are required to file this request.

How to fill out Molina Healthcare Request to Change Primary Care Provider?

To fill out the request form, members need to provide their personal information, current primary care provider details, their preferred new primary care provider, and any additional information as required on the form.

What is the purpose of Molina Healthcare Request to Change Primary Care Provider?

The purpose of the request is to allow members to select a different primary care provider that better meets their health needs or preferences.

What information must be reported on Molina Healthcare Request to Change Primary Care Provider?

The information that must be reported includes the member's name, contact information, member ID number, current primary care provider's name, and the name of the new primary care provider requested.