Form Dss-Ms-103-02/02 - Change Form, Medicaid Managed Are Provider Form

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MEDICAID MANAGED CARE
DSS-MS-103-02/02
PROVIDER FORM
State Office Use Only
Case Number:______________________ County:_______________________
Benefit Specialist:________________________ User ID:______________________
Annual Redetermination:_____________ County Transfer:_______________
BENEFIT SPECIALIST USE ONLY
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CHANGE FORM
SECTION 1 – GOOD CAUSE REASONS
When requesting a change in your Primary Care Provider selection you must clearly state your reasons for requesting
a change in detail.
I request a change of my Primary Care Provider for the following “good cause” reason(s) (check as many as
apply): You must include dates, times, length of waits, specific details, etc. If you FAIL to include the specific
information, your change request WILL BE DENIED. ALL CHANGE REQUESTS FOR “GOOD CAUSE”
REASONS ARE SUBJECT TO APPROVAL BY SD MEDICAID.
_______Long waiting periods to see the Doctor
_______Not being referred (authorized) to specialists when medically necessary
_______Doctor (or on-call staff) not available 24 hours a day, 7 days a week
_______Other______________________________________________________________________________________
__________________________________________________________________________________________________
Use the back of this form to give dates, times and specific details relating to the above indicated change reasons.
NOTE: IF YOUR CHANGE REQUEST IS APPROVED, YOUR NEW PCP DOES NOT
TAKE EFFECT IMMEDIATELY. CHANGE APPROVALS ARE EFFECTIVE ON
THE FIRST DAY OF THE MONTH AFTER APPROVAL.
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SECTION 2 – NEW PRIMARY CARE PROVIDER(S)
RECIPIENT’S NAME
RECIPIENT ID
PRIMARY CARE PROVIDER
PROVIDER
NUMBER
NAME
PCP CODE
0
1
2
3
4
5
6
I understand the Managed Care Program rules and requirements and also understand that by not following those rules and
requirements I may be responsible for payment of medical bills. Refer to your Recipient Handbook for more information.
Recipient’s Signature
Date
________________________________________
_______________________
Recipient’s Telephone Number________________________________
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