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ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM
PRIMARY CARE PHYSICIAN SELECTION AND CHANGE FORM
Member Information:
Name
*
First Name
Middle Initial
Last Name
Medicaid ID#
*
Social Security #
Birth Date (mm/dd/yyyy)
*
-
Month
-
Day
Year
Date
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email address
example@example.com
Requested New Doctor (Primary Care Provider):
I have picked the three (3) physicians named below in order of my preference to be my primary care physician. I understand only one (1) of them will be my primary care physician.
First choice for PCP
Please Select
Dr. Kelly Staley, Greenbrier
Dr. Chris Killingsworth, Conway
1. Doctors first and last name
*
Medicaid Provider ID#
*
Date of assignment
*
-
Month
-
Day
Year
Date
2. Doctors first and last name
Medicaid Provider ID#
Date of assignment
-
Month
-
Day
Year
Date
3. Doctors first and last name
Medicaid Provider ID#
Date of assignment
-
Month
-
Day
Year
Date
Reason for Request to Assign/Change Doctor (Primary Care Provider)
Choose all that apply. Select at least one.
Reasons for Request
New Member - made 1st time selection
Already patient with requested PCP
Requested PCP already sees family member
Member preference
Member moved
PCP hours didn't fit member need
Quality of care
Office wait times are too long
Takes too long to get an appointment
Office too far away/ hard to get to
Language / communication barrier
Other
Signatures:
Member Signature (or Legal Guardian if a minor)
*
Printed Name of Member (or Legal Guardian if a minor)
*
Date (mm/dd/yyyy)
-
Month
-
Day
Year
Date
DMS-2609 (Rev. 10/18)
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