Get the free Provider Change Request Form - Molina Healthcare

PROVIDER CHANGE FORM Today's Date: / / CURRENT PRACTICE INFORMATION ALL FIELDS IN THIS SECTION ARE REQUIRED Type of Provider: Ancillary Specialist Primary Care Provider Hospital Urgent Care Type 1

How to fill out provider change request form

How to fill out provider change request form

1. Step 1: Start by downloading the provider change request form from the official website of your insurance company.
2. Step 2: Carefully read the instructions provided on the form to ensure you understand the requirements and necessary information.
3. Step 3: Gather all the required documents and information before filling out the form. This may include your personal details, existing provider's information, and new provider's details.
4. Step 4: Begin filling out the form by accurately providing the requested information in each section. Pay attention to any mandatory fields or special instructions.
5. Step 5: Double-check all the information you have entered to avoid any errors or omissions. Make sure to provide updated and accurate contact information.
6. Step 6: If required, attach any supporting documents or letters along with the completed form. These may include a termination letter to the current provider or a letter of acceptance from the new provider.
7. Step 7: Review the completed form once again to ensure it is fully filled and all necessary attachments are included.
8. Step 8: Sign and date the form in the designated space to authenticate the request.
9. Step 9: Prepare a copy of the completed form and supporting documents for your records.
10. Step 10: Submit the provider change request form along with any additional required documents to the designated department or address as specified by your insurance company. You may choose to submit it online, via mail, or in person.
11. Step 11: Follow up with your insurance company to confirm the receipt of your request and to track the progress of the provider change. Keep a record of any reference number or communication regarding the change.
12. Step 12: Await confirmation from your insurance company regarding the approved provider change. This may be communicated through email, mail, or directly by phone.
13. Step 13: Once the provider change is approved, inform both your current and new provider about the change, ensuring a smooth transition of your healthcare services.

Who needs provider change request form?

1. Individuals who wish to switch their healthcare provider from their current one to a new one need to fill out a provider change request form.
2. Patients who are dissatisfied with their current provider's services or who have found a more suitable provider for their healthcare needs may also need to fill out this form.
3. People who have recently moved to a new location and need to change their healthcare provider due to geographical convenience also require this form.
4. Insurance policyholders who are changing their insurance plans or updating their network of providers also need to complete the provider change request form.
5. Any individual covered under a group insurance plan who wishes to switch from their current provider to a different one within the same network may also need to submit this form.

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What is provider change request form?

Provider change request form is a form used to request a change in service providers for a specific service or program.

Who is required to file provider change request form?

Any individual or organization who wishes to change their service provider for a specific service or program is required to file the provider change request form.

How to fill out provider change request form?

To fill out the provider change request form, one must provide their contact information, current service provider details, new service provider details, reason for the change, and any additional documentation required.

What is the purpose of provider change request form?

The purpose of the provider change request form is to officially request a change in service providers for a specific service or program.

What information must be reported on provider change request form?

The provider change request form must include contact information, current service provider details, new service provider details, reason for the change, and any additional documentation required.