Peachstate PCP Change Form

Member Data Change Form For Member Contact Information & PCP Change Requests

Please provide the member's information:
Name*

First NameLast Name
(Member Medicaid ID Number)
(Member Date of Birth)*

MonthDayYear
Date
Address*

(Current Street Address)

Street Address Line 2

(City)State / Province

(Zip Code)
(Contact Phone Number)*
Reason for Change from Assigned PCP:

Already a patient with requested PCPRequested PCP already sees family memberAssigned PCP is too farOffice wait time is too long for assigned PCPAppointment wait time is too long for assignedAssigned PCP does not accept ageOther
(Signature of Member or Responsible Party)*

Clear
(Date)*

MonthDayYear
Date
(Print Name of Responsible Party if Different from Member)
Birth Parent?

YesNo
-7 If "No", the name of the "Responsible Party" must match exactly what Peach State has on file for "Responsible Party" or change cannot be processed. Directions: Please fax Member Data Change forms, with a copy of the member ID card, if available, to Peach State Member Services Department at 1-800-659-7518. If you have questions about how to complete this form please call the Member Services Department at 1-800-704-1484.