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