Request to Change Primary Care Provider Form | Molina Healthcare
This form allows Molina Healthcare members to request a change of their primary care provider. The form requires member and new provider details, and must be signed and submitted via fax, email, or mail. It is applicable for Medicaid, Marketplace, Medicare, and Dual Options members.
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How do I fill this out?
Filling out this form is straightforward. Begin by entering the required personal and provider details. Be sure to sign and submit the form using the provided contact information.
How to fill out the Request to Change Primary Care Provider Form | Molina Healthcare?
1
Enter the member's personal details including name, Molina ID, and date of birth.
2
Include the details of any additional family members who are also Molina members.
3
Provide the current primary care provider’s name and the new provider’s information.
4
Sign the form and print your first and last name.
5
Submit the completed form via fax, email, or mail to the provided addresses.
Who needs the Request to Change Primary Care Provider Form | Molina Healthcare?
1
Medicaid members needing to change their primary care provider.
2
Molina Dual Options members who want to switch their primary care provider.
3
Marketplace members requesting a new primary care provider.
4
Medicare D-SNP enrollees changing their primary care provider.
5
Any Molina Healthcare member needing to update their primary care provider details.
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What are the instructions for submitting this form?
To submit this form, fill it out with the required details and send it via fax to (810) 275-9264, email it to MHMPROVIDERPCP.CHANGEREQUEST@Molinahealthcare.com, or mail it to Molina Healthcare of Michigan, Inc., Provider Services, 1321 S. Linden Road, Flint, MI 48532. My advice is to ensure all information is accurately entered and to keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
There are no specific deadlines provided for this form for 2024 and 2025, but submit it as needed when updating your primary care provider details.
What is the purpose of this form?
The purpose of this form is to facilitate the request for a change of primary care provider for Molina Healthcare members. This includes members under Medicaid, Marketplace, Medicare, and Molina Dual Options. By completing and submitting this form, members ensure that their primary care provider details are updated, which helps maintain the accuracy of medical records and services.
Tell me about this form and its components and fields line-by-line.
- 1. Member's Name: Enter the first and last name of the member.
- 2. Member's Molina ID #: Enter the Molina ID number of the member.
- 3. Date of Birth: Enter the date of birth of the member.
- 4. Additional Family Molina Members: Enter the names of any additional family members who are also Molina members.
- 5. Member's Address: Enter the member's address, including city, state, and ZIP code.
- 6. Member's Phone: Enter the member's phone number.
- 7. Current Primary Care Provider: Enter the name of the current primary care provider.
- 8. New Primary Care Provider: Enter the name of the new primary care provider and their address and phone number.
- 9. Signature: The member or delegated guardian must sign the form and print their name.
- 10. Date: Enter the date when the form is completed.
What happens if I fail to submit this form?
Failing to submit this form may result in continued assignment to the current primary care provider. This can affect the accuracy of your medical records and the coordination of care.
- Incorrect Primary Care Provider: Your records will indicate the current provider who you may no longer be seeing.
- Coordination of Care: Effective coordination between your healthcare providers may be disrupted.
- Claims Processing: Insurance claims may be processed based on inaccurate provider information.
How do I know when to use this form?
- 1. Changing Providers: When you decide to see a different primary care provider.
- 2. Relocating: When you move to a new location and need a provider closer to your new home.
- 3. Provider Availability: When your current provider is no longer available or cannot accommodate your schedule.
- 4. Specialty Care: When you require a provider with specific expertise or specialty.
- 5. Personal Preference: When you prefer to switch to a provider with whom you feel more comfortable.
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Can I include additional family members on the form?
Yes, there are fields available to enter the details of additional family members who are Molina members.
Where do I submit the completed form?
Submit the completed form via fax, email, or mail to the provided contact details on the form.
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