SoFHA Patient Forms

BlueCare PCP Change

Description:

The BlueCare PCP change form.

Code:

13.302

Issued:

07/20/2021

Revision:

Revised:

N/A

Primary Care Provider Change Request

If you are not filling out this form in the office, please print this document bring it with you to your next office visit.

Member Information

NameFirst, MI, Last

Date of Birth

Legal Guardian (if under 18)

BlueCare ID

Address Line 1

Address Line 2Optional

City

State

Zip Code

Phone Number

ID card will be mailed to the last reported address on file at TennCare. If you have recently moved, please contact the Tennessee Health Connection at 1-855-259-0701.

Provider Information

Effective Date

New PCP Name

Your signature will be required at your next office visit.