Fillable Specialist Acting as a Primary Care Provider Request (Cook Children's Health Plan)

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Specialist Acting as a Primary Care Provider Request (Cook Children's Health Plan)

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Specialist Acting as a
Primary Care Provider
Request Form
Please complete the Specialist Acting as a Primary Care Provider Request Form and return to Care Management
Fax: 682-885-8402 or toll free 844-643-8402
Phone: 888-243-3312
Provider Information
Provider Name: ___________________________________________________________________
Primary Specialty: __________________________Secondary Specialty: _____________________
Physical Address: __________________________ City: _____________ State: _____ Zip: ______
Phone Number: ___________________________ Fax Number: ____________________________
Tax ID Number: ________________ NPI Number: ____________TPI Number: ________________
Contact Name: ____________________________ Title: __________________________________
Contact Phone Number: _______________ Contact Fax Number: ___________________________
Contact Email Address: _____________________________________________________________
Member Information
Member Name: ___________________________________________________________________
Member ID Number: ___________________________ Date of Birth: _________________________
Address: _________________________________ City: ______________ State: ______ Zip: ______
Phone Number: _______________________ Alternate Phone Number: ______________________
Parent/Legal Guardian: _____________________________________________________________
Explain medical indication for Specialist acting as a Primary Care Provider for this patient:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________ ___________________
Completed by Date
RevDec19
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Specialist Acting as a Primary Care Provider Request (Cook Children's Health Plan)

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Completed 7 May 2021

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