Independent Health Pcp Change Form

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Frequently Asked Questions

How do I change my Primary Care Provider (PCP)?

PCP Change Request Form Your primary care provider (PCP) is the main person who delivers your healthcare. Complete this form to change your PCP or Advanced Medical Home (AMH) and fax to 866-840-4993. For urgent requests or immediate services, call Member Services at 844-594-5070.

How do I request personal care services from independent health?

Medicaid members who require Personal Care Services or Consumer Directed Personal Assistance Services will need to have their doctor complete this form. The form can be returned via fax to Independent Health at (716) 635-3820.

How do I attest for a patient’s PCP change?

Providers are asked to attest for a patient’s PCP change by signing, dating and faxing a completed form to fax number: 718-393-6635. Please download: Primary Care Provider Change Request Form . Access the Provider Attestation Statement and submit completion of training.

How do I submit a claim to independent health?

Use to submit a claim to Independent Health for processing. Use to lodge a written complaint against Independent Health or to appeal an adverse determination. You may also fax this form to (716) 635-3504.

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