Member Data Change Form

For Member Contact Information & PCP Change Requests

Part 1: Member Information

Please provide the member’s information:

* = required field

(Last Name)* (First Name)* (Middle Initial)

(Member Medicaid ID Number)* (Member Date of Birth)

(Current Street Address)

(City)

(Zip Code)

(Contact Phone Number)*

Part 2: PCP Change Request

Please provide PCP information: (only complete if member would like to change PCPs)

* = required field

(Requested PCP Full Name)* (PCP Provider ID)*

(Office Address)*

(City)

(Zip Code)

(Office Phone)*

Reason for Change from Assigned PCP:

 Already a patient with requested PCP

 Office wait time is too long for assigned PCP

 Requested PCP already sees family member

 Appointment wait time is too long for assigned

PCP

 Assigned PCP is too far

 Assigned PCP does not accept age

 Other_______________________________

(Signature of Member or Responsible Party) (Date)

(Print Name of Responsible Party if Different from Member)

Birth Parent? Yes or No -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.