How to Change Your Patient 1st Personal Doctor

Remember: 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:
  1. Fill in all of the blanks on this form.
  2. Be sure to answer all the questions on this form. If we do not have all of the information, we cannot change your doctor.

Dear Medicaid:


Today's Date:
      Year:   

I want to change personal doctors for:
 
The Medicaid Number of this person is:
 
The birthday of this person is:
      Year:   
     
The doctor I want to change to is:
 
If that doctor does not have a space, my second choice would be:
 


 IMPORTANT: The doctor you pick MUST be on the Patient 1st doctor list


I want to change doctors because:

I am not happy about the doctor I was assigned to.
I do not like the way my doctor treated me.
It is too hard to get an appointment with my doctor.
The doctor is not convenient to my home.
I have always seen another doctor.
I have trouble reaching my doctor after hours/weekends.
Other


My name is:
 
Address:
 
City:
 
Zip Code:
 
Phone: