If you submit this form, you do not need to call Medicaid!
Send your changes in right away. If you change doctors by the 15th day of the
month, you can start going to that doctor on the first day of the next month.
What you need to do:
Fill in all of the blanks on this form.
Be sure to answer all the questions on this form. If we do not have all of the
information, we cannot change your doctor.
IMPORTANT: The doctor you pick MUST be on the Patient 1st doctor list
I want to change doctors because: