Molina Healthcare Request to Change Primary Care Provider 2017-2025 free printable template

Request to Change Primary Care ProviderMembers Name: Members Molina ID #: Please print FIRST and LAST name. Members Address: (Please print.) City: State: ZIP: Members Phone: () Cell or Alt. #: ()

How to fill out molina healthcare change care provider form

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 your name, address, and member ID.
3. Indicate your current primary care provider's name and the reason for the change.
4. Provide the name and contact information of the new primary care provider you wish to switch to.
5. Sign and date the form to authorize the change request.
6. Submit the completed form via mail or fax to the appropriate Molina Healthcare address indicated on the form.

Who needs Molina Healthcare Request to Change Primary Care Provider?

1. Current members of Molina Healthcare who wish to change their primary care provider.
2. Individuals who are not satisfied with their current care or want to switch to a different provider for better services.
3. Members who have recently moved and need to select a new provider closer to their new residence.

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What is Molina Healthcare Request to Change Primary Care Provider?

The Molina Healthcare Request to Change Primary Care Provider is a form that allows members to formally request a change in their designated primary care provider within the Molina Healthcare system.

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

Members of Molina Healthcare who wish to change their assigned 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 Molina Healthcare Request to Change Primary Care Provider form, members need to provide their personal information, current primary care provider details, the desired new provider's information, and a reason for the change.

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

The purpose of the request is to streamline the process for members who wish to switch their primary care providers, ensuring they receive care that best meets their needs.

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

Members must report their name, member ID, current primary care provider, requested new primary care provider, reason for the change, and contact information on the request form.