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Primary Care Provider Change Request Fax the completed form to 7183936635Member Name:DOB:Fidel is Care Member ID: In the past month, I have VISITED NOT VISITED a primary care provider (PCP). (If visited
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How to fill out fidelis care change primary
How to fill out fidelis pcp change form:
01
Begin by obtaining the fidelis pcp change form from the appropriate source. This may involve visiting the fidelis website or contacting their customer service.
02
Read the instructions provided on the form carefully. Make sure you understand the purpose of the form and the information it requires.
03
Start filling out the form by entering your personal details, such as your name, address, phone number, and date of birth. Provide accurate and up-to-date information.
04
Next, provide the necessary information regarding your current primary care physician (PCP). This may include their name, address, phone number, and any other required details.
05
Indicate the reason for wanting to change your PCP. This can be a personal preference, relocation, or any other valid reason.
06
If applicable, provide the name and contact information of the new PCP you wish to switch to. Ensure you have researched and selected the appropriate PCP for your needs.
07
Review the completed form for any errors or omissions. Double-check that all the required fields have been filled out correctly.
08
Sign and date the form to validate your request for a change in PCP.
09
Make a copy of the filled-out form for your records before submitting it to fidelis.
10
Submit the completed fidelis pcp change form according to the instructions provided. This may involve mailing it to a specific address or submitting it online.
Who needs fidelis pcp change form:
01
Any member of fidelis health insurance who wishes to switch their primary care physician (PCP) needs the fidelis pcp change form.
02
Individuals who have moved to a new location and need to find a new PCP within their fidelis network will require this form.
03
Those who have had changes in their healthcare needs or preferences and want to switch to a different PCP within fidelis network will also need this form.
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What is fidelis change doctor?
Fidelis change doctor is a form used by members of Fidelis Care to update their primary care physician or specialist.
Who is required to file fidelis change doctor?
Members of Fidelis Care who wish to change their healthcare provider are required to file the fidelis change doctor form.
How to fill out fidelis change doctor?
To fill out the fidelis change doctor form, provide your member information, the name of the current doctor, the name of the new doctor you wish to switch to, and sign the form as needed.
What is the purpose of fidelis change doctor?
The purpose of the fidelis change doctor form is to officially request a change of healthcare provider within the Fidelis Care network.
What information must be reported on fidelis change doctor?
The information that must be reported includes your member ID, current doctor's name, new doctor's name, and your signature.
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