New Primary Care Provider (PCP) Change Request Form

Date: 04/05/18

Heritage Health (Medicaid):

Through the efforts of the Heritage Health Administrative Simplification Committee, a new PCP ChangeRequest Form for provider use has been developed for Heritage Health members. Nebraska Total Care has posted the new PCP Change Request Form on the Practice Improvement Resource Center page of our website.

Members have the right to choose and change their PCP, and may ask providers for assistance with this process. The new form will be accepted by all three Heritage Health MCOs and can be used for any Heritage Health member. The fax information for each MCO is included at the top of the form.

This form is primarily intended to be used by providers when they assist members with the PCP change process. Members will continue to have the right to change PCPs without the assistance of a provider through the Secure Member Portal, the Member PCP Change Form that is included in their new member materials, or by calling Member Services.

If you need assistance accessing or completing the form or have other questions, please contact your identified Provider Relations Representative.