SD EForm - 1077 V2
MEDICAID MANAGED CARE PROVIDER FORM 

State Office Use Only

CHANGE FORM
SECTION 1 - GOOD CAUSE REASONS

When requesting a change in your Primary Care Provider selection you must clearly state your reasons for requesting a chang in detail.

I request a change of my Primary Care Provider for the following "good cause" reason(s) (check as many as apply): You must include dates, times, length of waits, specific details, etc. If you FAIL to include the specific information, your change request WILL BE DENIED. ALL CHANGE REQUESTS FOR "GOOD CAUSE" REASONS ARE SUBJECT TO APPROVAL BY SD MEDICAID







Use the back of this form to give dates, times and specific details relating to the above indicated change reasons.

NOTE: IF YOUR CHANGE REQUEST IS APPROVED, YOUR NEW PCP DOES NOT TAKE EFFECT IMMEDIATELY. CHANGE APPROVALS ARE EFFECTIVE ON THE FIRST DAY OF THE MONTH AFTER APPROVAL.

SECTION 2 - NEW PRIMARY CARE PROVIDER(S)
RECIPIENT'S NAME
RECIPIENT ID NUMBER
PRIMARY CARE PROVIDER NAME
PROVIDER PCP CODE
0
1
2
3
4
5
6
7
8
9

I understand the Managed Care Program rules and requirements and also understand that by not following those rules and requirements I may be responsible for payment of medical bills. Refer to the Recipient Handbook for more information
  Recipient's Signature:     Date: 
  Recipient's Telephone Number:  
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