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Request to Change Primary Care Provider
Medicaid (Healthy MI and CSS)Molina Dual Options (MI Health Link)Members Name:Marketplace Medicare (DSP)Members Molina ID #:
Date of Birth:Please print FIRST
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How to fill out provider-request-change-pcp-form
How to fill out provider-request-change-pcp-form
01
Obtain a provider-request-change-pcp-form from your healthcare provider or insurance company.
02
Fill out your personal information, such as your name, address, and contact information.
03
Provide your current primary care physician's information, including their name, address, and contact details.
04
Indicate the reason for wanting to change your primary care physician.
05
If required, provide the name and contact information of the new primary care physician you wish to switch to.
06
Sign and date the form.
07
Submit the completed provider-request-change-pcp-form to your healthcare provider or insurance company as instructed.
Who needs provider-request-change-pcp-form?
01
Anyone who wishes to change their primary care physician needs the provider-request-change-pcp-form. This form is typically used by individuals who are not satisfied with their current primary care physician and want to switch to a different one within their healthcare network.
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What is provider-request-change-pcp-form?
Provider-request-change-pcp-form is a form used to request a change in the primary care physician (PCP) for a patient.
Who is required to file provider-request-change-pcp-form?
The patient or their authorized representative is required to file the provider-request-change-pcp-form.
How to fill out provider-request-change-pcp-form?
The provider-request-change-pcp-form can be filled out by providing the patient's information, current PCP details, reason for requesting a change, and any supporting documentation.
What is the purpose of provider-request-change-pcp-form?
The purpose of provider-request-change-pcp-form is to officially request a change in the primary care physician for a patient.
What information must be reported on provider-request-change-pcp-form?
The provider-request-change-pcp-form must include information such as patient's name, date of birth, current PCP details, reason for change, and any relevant medical history.
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