Fillable STAR Health Primary Care Provider Selection Form If (Superior HealthPlan)

Fill Online, Printable, Fillable, Blank STAR Health Primary Care Provider Selection Form If (Superior HealthPlan) Form

Use Fill to complete blank online SUPERIOR HEALTHPLAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STAR Health Primary Care Provider Selection Form If (Superior HealthPlan)

On average this form takes 24 minutes to complete

The STAR Health Primary Care Provider Selection Form If (Superior HealthPlan) form is 2 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 86 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Superior HealthPlan forms online.

BROWSE SUPERIOR HEALTHPLAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
5900 E. Ben White Blvd.
Austin, TX 78741
STAR Health
Primary Care Provider Selection Form
If you haven’t done so already, please choose a Primary Care Provider (doctor) for your child. You can find a
list of doctor’s in the directory included in this packet under “Primary Care Providers.”
After you choose a doctor for your child, please complete the form below and return it to us by faxing it to 1-
866-626-6069. Or you can simply call us at 1-866-912-6283.
Child’s Name Child’s DFPS and
Medicaid ID # Birth Date
Doctor’s First and
Last Name and
Telephone Number
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
________________________ _______________________ _______________
Medical Consenter Name Signature DFPS ID #
____
____________________________
Day phone # in case we have to call you.
Please remember: Only the child’s Medical Consenter can choose or change a doctor. If you are the
Caregiver, but not the Medical Consenter, please call the Medical Consenter for help.
If you need help filling out this form, please call Member Services at 1-866-912-6283. We will be more than
happy to help you!
Superior HealthPlan
STAR Health Program
SuperiorHealthPlan.com
20100601 SHP PCP Selection FC
click to sign
signature
click to edit
5900 E. Ben White Blvd.
Austin, TX 78741
STAR Health
Forma de Selección de Proveedor de Cuidado Primario
Si todavía no lo ha hecho, por favor, escoja a un proveedor de cuidado primario (doctor) para su hijo. Puede
encontrar una lista de proveedores de cuidado primario en el directorio que se incluye en este paquete bajo
"Proveedores de Cuidado Primario".
Después de escoger un médico para su hijo o hija, por favor complete el formulario a continuación y
devuélvanoslo por fax al 1-866-626-6069. O solo llámenos al 1-866-912-6283.
Nombre del niño
Número de identificació
n del niño
del DFPS y de Medicaid
Fecha de
nacimiento:
Nombre, apellido y
teléfono del doctor
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_______________________ ________________ __________________________
Nombre del otorgante de Firma Número de identificación consentimiento médico
del DFPS
____
____________________________
Teléfono durante el día por si tenemos que llamarlo.
Por favor, recuerde: solo el otorgante de consentimiento médico puede escoger o cambiar a un
doctor. Si usted es el cuidador, pero no el otorgante de consentimiento médico, por favor, llame al otorgante
de consentimiento médico para pedirle ayuda.
Si necesita ayuda para llenar esta forma, por favor, llame al Servicios para miembros al 1-866-912-6283. ¡Nos
complacerá ayudarle!
Superior HealthPlan
Programa de STAR Health
SuperiorHealthPlan.com
20100601 SHP PCP Selection FC
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STAR Health Primary Care Provider Selection Form If (Superior HealthPlan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document