Change Pcp Amerigroup PDF Details

At the heart of managing one’s health care under the Amerigroup Community Care insurance plan lies the ability to choose or change one’s primary care provider (PCP), the medical professional who serves as the main point of contact for an individual's health care. The Change PCP Amerigroup form is essential for members who need to make a switch in their PCP for various reasons, including but not limited to dissatisfaction with current care, relocation of the member or the provider, logistics such as appointment availability, or issues with the auto-assignment of a PCP. This form, which requires between 24 to 72 hours to be processed, necessitates details about the member, including their full name, date of birth, legal guardian’s name if applicable, and various identification numbers. It also demands information about the new PCP such as their name, contact details, and the effective date of the change. For those in urgent need of a switch, a direct call to Member Services is recommended. Additionally, the form mandates the member or guardian's signature to validate the request and asks for the reason behind the PCP change, allowing the member to provide a detailed explanation to ensure that their needs are accurately understood and met. It’s a clear process intended to ensure that members can efficiently manage their health care with minimal disruption.

QuestionAnswer
Form NameChange Pcp Amerigroup
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup change pcp, do i have to change my childs primary care provider, maryland amerigroup pcp change form fillable, amerigroup pcp change form 2019

Form Preview Example

AMERIGROUP COMMUNITY CARE

PRIMARY CARE PROVIDER REASSIGNMENT REQUEST

ALLOW 24‐72 HOURS FOR PROCESSING

Your primary care provider (PCP) is the main person who provides you with health care. Complete this form if you would like to change your current PCP.

For urgent requests, please call Member Services toll free at 1‐800‐600‐4441 (TTY 711).

MEMBER INFORMATION

Member’s full name Member’s date of birth

Legal guardian’s name (if younger than age 18)

[Amerigroup] ID card number or Social Security number

Medicaid ID card number State of residence Member phone number

PCP INFORMATION

Date of request (effective date of PCP change) Name of new PCP

Name of new PCP staff member processing request (if applicable)

New PCP phone number New PCP fax number New provider ID number New provider address

TO BE COMPLETED BY MEMBER OR GUARDIAN:

I am requesting that my PCP/my child’s PCP be changed to the name listed above.

SIGNATURE OF MEMBER/RESPONSIBLE PARTY:

REASON FOR REASSIGNMENT:

 

 

Auto‐assign/Choice issue

Member/PCP relocation

PCP office inconvenient

Unhappy with current PCP

Appointment availability

Other

Please give us more detail:

 

 

 

 

 

FAX PCP REQUESTS TO: 1‐866‐840‐4993

FORMS WILL NOT BE PROCESSED

 

 

 

MF‐NJ‐0010‐16

UNLESS ALL FIELDS ARE COMPLETED

OMHC #078‐16‐42

 

 

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medicaid change pcp texas REASON FOR REASSIGNMENT, Unhappy with current PCP, Please give us more detail, MemberPCP relocation Appointment, PCP office inconvenient Other, FAX PCP REQUESTS TO, MFNJ OMHC, and FORMS WILL NOT BE PROCESSED UNLESS blanks to complete

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