Edit, Download, and Sign the Tennessee Medicare Advantage PCP Change Request Form
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How do I fill this out?
Filling out this form is straightforward. Start by entering your personal information as the member or guardian. Lastly, provide the details of your new Primary Care Provider.
How to fill out the Tennessee Medicare Advantage PCP Change Request Form?
1
Begin by entering your full name and date of birth.
2
Provide the member's ID card number and contact information.
3
Fill in the new Primary Care Provider's details including their tax ID and contact information.
4
Sign the form if completed by someone other than the member.
5
Submit the form via mail or fax to the provided address.
Who needs the Tennessee Medicare Advantage PCP Change Request Form?
1
Medicare members switching their Primary Care Provider.
2
Caregivers of minors needing to change the PCP.
3
Individuals managing a family plan and needing to update provider information.
4
Patients who have moved and require a new local healthcare provider.
5
Anyone needing to ensure their healthcare preferences match their provider network.
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What are the instructions for submitting this form?
Submit the completed form to BlueCross BlueShield of Tennessee's Medicare Advantage Operations team. You can mail it to 1 Cameron Hill Circle, Ste 0005, Chattanooga, TN 37402-0005. Alternatively, fax your request to (423) 535-5498.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, it is crucial to submit this form to ensure timely updates to your Primary Care Provider information. Key dates to remember include submission deadlines associated with healthcare enrollment periods. Be proactive in managing your health plan changes.
What is the purpose of this form?
The primary purpose of this form is to facilitate changes in the Primary Care Provider for Medicare members. It ensures that members receive continuous and appropriate healthcare. By requesting a change, members can align their healthcare needs with available providers.
Tell me about this form and its components and fields line-by-line.
- 1. Full Name: Enter your complete name.
- 2. Date of Birth: Provide your date of birth.
- 3. Member ID Card Number: Input your unique member ID.
- 4. Phone Number: Provide a contact number.
- 5. Address: List your current address including city, state, and zip.
- 6. New Primary Care Provider Name: Indicate the name of the new PCP.
- 7. PCP Practice Tax ID Name: Include the tax ID registered to the practice.
- 8. Provider ID/NPI Number: Enter the National Provider Identifier number.
What happens if I fail to submit this form?
Failure to submit this form may lead to delays in changing your Primary Care Provider. This could affect your healthcare access and coverage. Ensuring timely submission prevents any disruption in your care.
- Delayed Provider Change: Changes might not take effect in a timely manner.
- Impact on Healthcare Services: Failure to submit could affect the availability of necessary healthcare services.
- Confusion with Current Provider: Not updating your PCP may lead to confusion in your care management.
How do I know when to use this form?
- 1. Changing Providers: When you have decided to switch to a new doctor.
- 2. Relocation: If you've moved to a different area and need a local provider.
- 3. Family Dynamics: When children require different healthcare providers.
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