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
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.