MEDICAID MANAGED CARE PRIMARY CARE PHYSICIAN REASSIGNMENT REQUEST ALLOW 24 - 72 HOURS FOR PROCESSING YOUR PRIMARY CARE PHYSICIAN (PCP) IS THE MAIN PERSON WHO GIVES YOU HEALTH CARE. COMPLETE THIS FORM TO CHANGE YOUR PCP. For urgent requests, please call Member Services toll free at 1-800-600-4441. MEMBER INFORMATION Member’s Full Name Member’s Date of Birth Legal Guardian’s Name (If younger than age 18) Amerigroup ID Card Number or Social Security Number State of Residence Medicaid ID Card Number Patient Phone Number PCP INFORMATION Date of Request (Effective Date of PCP Change) Name of New PCP Name of New PCP staff member processing request (If applicable) Telephone Number of New PCP New PCP Fax Number New Provider ID Number New Provider Address TO BE COMPLETED BY PATIENT OR GUARDIAN: I am requesting that my PCP/my child’s PCP be changed to the name listed above. SIGNATURE OF PATIENT/RESPONSIBLE PARTY: SIGNATURE OF NEW PCP (Not required): REASON FOR REASSIGNMENT: Autoassign/Choice Issue Unhappy with PCP Member/PCP Relocation Appointment Availability PCP Office Inconvenient Other/ No Reason Please give us more detail: FAX PCP REQUESTS TO: 1-866-840-4993 FORMS WILL NOT BE PROCESSED UNLESS ALL FIELDS ARE COMPLETED Do you need help with this letter? Is it because you have a health, mental health or learning problem or a disability? Or do you need help in another language? If so, you have a right to get help, and we can help you. Call Amerigroup Community Care at 1-866-840-4991. Do you have a mental illness and need help with this letter? The TennCare Partners Advocacy Line can help you. Call them for free at 1-800-758-1638. If you have a hearing or speech problem, you can call us on a TTY/TDD machine. Our TTY/TDD number is 1-866-771-7043. Hay una línea telefónica en español para los consumidores hispanos de TennCare. Llame a la línea de español de Amerigroup Community Care al teléfono 1-866-840-4991. We do not allow unfair treatment in TennCare. No one is treated in a different way because of race, color, birthplace, religion, language, sex, age or disability. Do you think you’ve been treated unfairly? Do you have more questions or need more help? If you think you’ve been treated unfairly, call the Family Assistance Service Center for free at 1-866-311-4287. In Nashville, call 743-2000. Interpretation and translation services are free to members. For details, please call Member Services at 1-866-840-4991. Foreign Language Lines — call if you need help and need to speak with someone in one of these languages: (Arabic) (Bosnian) (Kurdish-Badinani) (Kurdish- Sorani) (Somali) Español 1-877-652-3046 1-877-652-3069 1-877-652-3046 1-877-652-3046 1-877-652-3054 1-800-254-7568 (Spanish) (Vietnamese) 1-800-269-4901