Fillable Health Plan Change Request (NC Dept of Health and Human Services)

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Health Plan Change Request (NC Dept of Health and Human Services)

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The Health Plan Change Request (NC Dept of Health and Human Services) form is 2 pages long and contains:

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  • 26 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

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Health Plan Change Request
Use this form to request to change your
health plan.
MEDICAID EB PLAN CHA ENG 190321
If you want to request to change your health plan:
1. Talk to your health plan first. There may be a way to stay with your plan.
2. If you still want to change your plan, fill out this form. Or call us at 1-833-870-5500
(TTY: 1-833-870-5588).
3. Mail this form to NC Medicaid, PO Box 613, Morrisville NC 27560. Or fax the form
to 1-833-898-9655.
⊲ Tell us about the head of household
First name MI
Last name
Date of birth Medicaid ID Number
Address
City State ZIP Code
What is your phone number?
Home Cell
What is your email address?
What do you speak at home? English Spanish Other?
Person 1
Name Date of birth ID Number
⊲ Write the name of the plan you want here.
Do you want this health plan for everyone in the household?
Yes No
⊲ Tell us why you want to change your plan (Put an X next to the reason or reasons you want to
change plans. We may ask you to provide proof to support your request).
Cannot get all needed health services
in one plan
Long Term Services & Supports (LTSS)
provider no longer in plan
Current plan cannot meet medical
needs
Family member is in a different plan
Poor performance of plan
Plan will not cover service for moral
or religious reasons
Other (please explain why)
________________________________________________________
Questions? Go to ncmedicaidplans.gov. Or call us at 1-833-870-5500 (TTY: 1-833-870-5588),
7 a.m. to 5 p.m., Monday through Saturday. We can speak with you in other languages.
To get this information in other languages or formats
such as large print or audio, call 1-833-870-5500.
Person 2
Name Date of birth ID Number
⊲ Write the name of the plan you want here.
⊲ Tell us why you want to change your plan (Put an X next to the reason or reasons you want to
change plans. We may ask you to provide proof to support your request).
Cannot get all needed health services
in one plan
Long Term Services & Supports (LTSS)
provider no longer in plan
Current plan cannot meet medical
needs
Family member is in a different plan
Poor performance of plan
Plan will not cover service for moral
or religious reasons
Other (please explain why)
________________________________________________________
Person 3
Name Date of birth ID Number
⊲ Write the name of the plan you want here.
⊲ Tell us why you want to change your plan (Put an X next to the reason or reasons you want to
change plans. We may ask you to provide proof to support your request).
Cannot get all needed health services
in one plan
Long Term Services & Supports (LTSS)
provider no longer in plan
Current plan cannot meet medical
needs
Family member is in a different plan
Poor performance of plan
Plan will not cover service for moral
or religious reasons
Other (please explain why)
________________________________________________________
Sign and date
By signing below, I am stating that all information on this form is true. I know that if I gave false
information on this form, my request to change my health plan may be denied.
⊲ Head of household or guardian sign here Date
⊲ Authorized representative If you are an authorized representative for this household, fill out this
section and sign below.
Name of authorized representative Phone number
Address (street, city, state, ZIP Code)
⊲ Authorized representative sign here
Date
2
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Health Plan Change Request (NC Dept of Health and Human Services)

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Completed 28 January 2021

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