SoFHA
Patient Forms

Bluecare PCP Change Form


Description:

The BlueCare PCP change form.


Code:

15.202

Issued:

04/29/2022

Revision:

1

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












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



Your signature will be required at your next office visit.