SoFHA Patient Forms

Amerigroup PCP Change Form

Description:

The Amerigroup PCP change form.

Code:

15.201

Issued:

04/29/2022

Revision:

Revised:

N/A

Your primary care physician (PCP) is the main person who gives you healthcare. Complete this form to change your PCP.

For urgent requests, please call Member Services toll free at 1-800-600-4441.

NameFirst, MI, Last

Date of Birth

Legal Guardian (if under 18)

Amerigroup ID or SSN

State

Medicaid ID

Phone Number

Effective Date

New PCP Name

Your signature will be required at your next office visit.