Get the free THP PCP Change Request Form - Trusted Health Plan - dphhs mt
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SLTC244 (Rev 1/2017)Agency Based Provider Agency Intake Internal Quality Assurance Review Worksheet Name of Member: Date of Intake visit: PCP Form with signatures Service Plan with signatures MPH
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How to fill out thp pcp change request
How to fill out thp pcp change request
01
To fill out the THP PCP change request, follow the steps below:
02
Obtain the THP PCP change request form from the designated source.
03
Fill out your personal information, including your name, address, and contact details.
04
Provide the details of your current THP PCP, such as the name of your current primary care physician and their contact information.
05
Specify the reason for the change request, including any relevant medical or personal factors.
06
If applicable, provide the name and contact information of the new primary care physician you wish to switch to.
07
Sign and date the form, ensuring all the information provided is accurate and complete.
08
Submit the filled-out THP PCP change request form to the appropriate authority or department as instructed.
09
Keep a copy of the form for your records.
10
Note: It is important to follow the specific instructions and guidelines provided by your healthcare provider or insurance company while filling out the THP PCP change request.
Who needs thp pcp change request?
01
Anyone who wishes to change their primary care physician (PCP) under the THP (Tertiary Healthcare Program) may need to submit a THP PCP change request. This request may be required by individuals who are dissatisfied with their current PCP and want to switch to a new one within the THP network. Additionally, individuals who have experienced a change in their medical circumstances, such as a new diagnosis or need for specialized care, may also need to request a change in their PCP. It is best to consult with your healthcare provider or insurance company to determine if you need to submit a THP PCP change request and to understand the specific requirements and procedures involved.
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What is the thp pcp change request?
The thp pcp change request is a form used to request changes to the Primary Care Physician (PCP) in the Total Health Plan (THP) system.
Who is required to file thp pcp change request?
Any member of the Total Health Plan (THP) system who wishes to change their Primary Care Physician (PCP) is required to file a thp pcp change request.
How to fill out thp pcp change request?
The thp pcp change request form can be filled out online or in-person by providing your personal information, current PCP details, and the new PCP information.
What is the purpose of thp pcp change request?
The purpose of the thp pcp change request is to update the system with the member's current Primary Care Physician (PCP) information.
What information must be reported on thp pcp change request?
The thp pcp change request form requires information such as member ID, current PCP details, new PCP details, reason for change, and effective date of the change.
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