Medicare Advantage Primary Care Provider (PCP) Change Request Form

Attn: Member Services Fax: 844-881-4857
Medicare Advantage Primary Care Provider (PCP) Change Request Form
UnitedHealthcare Medicare Advantage plan members can change their PCP at any time, for any reason. To help them make this change, please help the member fill out this form. By filling out and faxing this request form, members are authorizing UnitedHealthcare Medicare Advantage plan to process a PCP change at their request. Members can also make a PCP change request by calling Member Services at the phone number listed on the back of their ID card. Changes submitted to UnitedHealthcare will generally be processed within 1-2 business days after the form is faxed to member services and will be effective on the 1st day of the following month. Referrals previously submitted by the member’s former PCP will not be affected by the change in PCP. Please help the member fill out the entire form, then fax the form to UnitedHealthcare Member Services on behalf of the

member at 844-881-4857. This form must be signed by the member and can only be used for the member signing the form. Member Statement
Name
Name (First Name, Last Name)
I wish to change my primary care provider to:
(First, Last) of
(First, Last) of (group practice name if applicable)
SC House Calls, Inc. Tax ID: 20-5227543
I am currently a part of (plan name) Member:
Member Signature

Clear
Date

MonthDayYear
Date
Member Information
Name (Last, Middle, First)
Address

Street Address

Street Address Line 2

CityState

ZIP
Phone Number
Member Date of Birth

MonthDayYear
Date
Member ID #
Provider Information
Previous PCP’s Name (Last, First)
New PCP’s Name (Last, First)
New PCP’s UnitedHealthcare ID #
New PCP’s Address (Street, City, State, ZIP)
Reason for Changing Your PCP
Member Choice
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número de teléfono gratuito para miembros que aparece en la tarjeta de ID. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請撥打您會員卡所列的免付費會員電話號碼.

MonthDayYear
Date
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Attn: Member Services Fax: 844-881-4857

Medicare Advantage Primary Care Provider (PCP) Change Request Form

Member Information

Provider Information