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Change Pcp Form

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CHANGE PCP

Fax Request Form

Please complete the entire form and fax to: 1‐866‐888‐1129

MEMBER INFORMATION

Select Program

Washington Healthy Options

Washington Basic Health

Member Name __________________________________________ Member ID # ________________________

Member Address _____________________________________________________________________________

Member City ________________________________________ State _______________ ZIP code _________

Member Phone Number____________________

Signature of Member or Authorized/Responsible Party _______________________________ Date _________

(Forms submitted without a signature will not be processed)

Print Name of Authorized/Responsible Party ________________________________________________________

A new ID card will be mailed to the address last reported to the Healthcare Authority (HCA). If you have recently moved, please

call your Community Services Office (CSO) at 1‐877‐501‐2233 TTY 1‐800‐209‐5446 or use 711

CURRENT PCP INFORMATION

Current PCP Name:

______

Reason for change (please check one):

Member moved to new service area

PCP not accepting new patients

PCP retired

PCP left location

PCP not accepting existing patients

PCP deceased

Other (please explain)_______________________________________________________________________

___________________________________________________________________________________________________________________

NEW PCP INFORMATION

FQHC/RHC?

Yes

No (If Yes, PCP assignment will be made to the group not individual practitioners)

Name

_____

NPI

Service Address

_____

Tax ID

City

______ State _______ ZIP Code

______

Established Patient (Change will be effective on the first of the current month)

New Patient (Change will be effective on the first of the next month)

Office Contact Name/Phone ______________________________________ Fax Number __________________

Office Contact Signature______________________________________ Date

_____________

Please contact UnitedHealthcare Community Plan Member Services with questions 1‐877‐542‐8997

NOTE: All fields must be completed, incomplete forms will not be processed

Coverage provided by UnitedHealthcare of Washington, Inc.

Change Pcp Form

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