BCN Form - PCP Change

Blue Care Network - Primary Care Provider Update Form
You are being provided this form by Avenue Health to update your Blue Care Network (BCN) insurance to your correct Primary Care Provider (PCP). The reason you are given this form is because BCN requires to have your correct PCP on file. If you do not have your updated PCP on file, this may result in rejected claims or higher copay costs. To be a patient at Avenue Health, you are required to complete this form.

For your appointments, you will be seeing Michelle Gormas, PA-C or Tiffany Gose, PA-C. Melody Angel, MD is the supervising doctor at Avenue Health who will be listed as your PCP through your insurance.

To complete this form, you will need the information from your insurance card.
Please use the drop down to select Melody Angel, MD*
Please use the drop down to select her NPI number*
Have you been seen at Avenue Health in the past 12 months?*
Physician Selection Effective Date: (The day you were/are first seen at Avenue Health or and estimated date)*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Please refer to the image below to identify the location on your insurance card where the following information can be found.
Subscriber Name:*
Issuer #:*
Group Number*
Subscriber Signature*

Clear
Date*

MonthDayYear
Date
***PLEASE NOTE: Changes are limited to one every 30 days. All changes become effective two business days after Blue Care Network receives your request---Unless you request a specific effective date. You can select this date on your form for your date to be effective. If you change yourr primary care physician while you're being treated by a specialist, your new doctor must re-authorize the treatment you are receiving. Without this authorization, your treatment may not be covered.***
Should be Empty:

Blue Care Network - Primary Care Provider Update Form

Please refer to the image below to identify the location on your insurance card where the following information can be found.