Form DMS-2609 - Primary Care Physician Selection and ...
ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM
PRIMARY CARE PHYSICIAN SELECTION AND CHANGE FORM
Member Information:
First Name Last Name Middle Initial
Medicaid ID# Social Security #
Birth Date (mm/dd/yyyy)
Mailing Address City State Zip
Home Phone Cell Phone
Email address
Requested New Doctor (Primary Care Provider):
I have picked the three (3) physicians named below in order of my preference to be my primary care physician. I understand only one (1) of them will be my primary care physician.
1.
Doctors first and last name Medicaid Provider ID# Date of assignment
2.
Doctors first and last name Medicaid Provider ID# Date of assignment
3.
Doctors first and last name Medicaid Provider ID# Date of assignment
Reason for Request to Assign/Change Doctor (Primary Care Provider)
Choose all that apply. Select at least one.
← New Member – made 1st time selection
← Already patient with requested PCP
← Requested PCP already sees family member
← Member preference
← Member moved
← PCP hours didn’t fit member need
← Quality of care
← Office wait times are too long
← Takes too long to get an appointment
← Office too far away/ hard to get to
← Language / communication barrier
← Other (please specify)
Signatures:
Member Signature (or Legal Guardian if a minor)
Printed Name of Member (or Legal Guardian if a minor)
Date (mm/dd/yyyy)
DMS-2609 (Rev. 10/18)
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