Get the free Provider Change Form - Arizona Foundation
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326 E. Coronado Rd. Phoenix, AZ 85004 602-252-4042 or 800-624-4277 provider relations azfmc.com Fax: 602-495-8684 Page 1 of 2 Provider Change Form Please note: Provider is entirely responsible for
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How to fill out provider change form
How to fill out provider change form:
01
Obtain the provider change form: The first step is to obtain the provider change form. You can typically find this form on the website of your insurance company or by contacting their customer service hotline.
02
Fill out personal details: Begin by filling out your personal details accurately. This includes your full name, address, phone number, and any other information that the form requires.
03
Provide current provider information: Next, you will need to provide information about your current healthcare provider. This may include the name of the doctor or facility, their address, and phone number.
04
Specify the effective date: Indicate the desired effective date for the provider change. Make sure to check with your insurance company regarding any specific guidelines or restrictions regarding the effective date.
05
Choose the new provider: Select the new healthcare provider that you wish to switch to. This includes providing their name, address, and contact details.
06
Explain the reason for the change: Some provider change forms may ask for a brief explanation of why you are switching to a new provider. Be concise and clear in your response.
07
Attach any necessary documentation: Depending on the requirements of your insurance company, you may need to attach supporting documentation to the form. This could include things like a referral from your current provider or any medical records that need to be transferred to the new provider.
08
Review and submit: Before submitting the form, take a moment to review all the information you have filled out. Make sure everything is accurate and complete. If there are any errors, correct them before submitting the form.
Who needs a provider change form?
The provider change form is typically required for individuals who have health insurance coverage and wish to switch their healthcare provider. This form is necessary to inform the insurance company about the change and update their records accordingly. Whether you are switching due to changes in your healthcare needs, proximity to a different provider, or personal preference, it is important to complete the provider change form to ensure a smooth transition and continued coverage.
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