Foundational Community Supports
Provider Change Request Form
Complete this form to change your Foundational Community Supports (FCS) provider.
Please send completed requests by email to FCSTPA@amerigroup.com or by fax to 1-844-470-8859.
This can also be sent in the mail to: FCS Amerigroup, 705 Fifth Ave. S., Ste. 300, Seattle, WA 98104.
For questions, call FCS at 1-844-451-2828.
*Indicates a required field
Enrollee information
*First name: *Date:
*Last name: *Date of birth:
Phone number: ProviderOne number:
Address: *City, State, ZIP:
*Enrolled in: Supportive housing Supported employment
Current provider information
*Name of current provider: Phone number:
City, State, ZIP: Number of units already used:
New provider information
*Name of new provider: Phone number:
Address: *City, State, ZIP:
Reason for the request (select all that apply):
I did not choose my last provider.
I moved or my provider moved.
I was unhappy with my last provider.
My provider’s office was too far away or
I had trouble getting appointments with
too hard to get to.
my last provider.
Other: __________________________________
Enrollee consent
I give consent to share my information with other health and social care professionals for the purpose of
obtaining supportive housing and/or supported employment services.
*Enrollee signature: ________________________________________ Date: _______________
MF-WA-0079-19 www.myamerigroup.com/washington-fcs
