Peach State Health Plan

For Member Contact Information & PCP Change Requests

Part 1: Member Information

Please provide the member’s information:

Last Name:

First Name:

Middle Initial:

Member Medicaid ID Number

Member Date of Birth

Contact Phone Number

Current Street Address

City:

Zip Code:

Part 2: PCP Change Request

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

Requested PCP Full Name

PCP Provider ID

Office Phone

Office Address

City:

Zip Code:

Reason for Change from Assigned PCP:

Requested PCP already sees family member

Other

Office wait time is too long for assigned PCP

Appointment wait time is too long for assigned PCP

Assigned PCP does not accept age

If other, specify:

Signature of Member or Responsible Party

Date:

Print Name of Responsible Party if Different from Member

Birth Parent?

Yes No

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.

Your information will be encrypted.