How To Complete Your Enrollment Form
To join an MCP or to change your current MCP you need only to complete the enrollment form and mail it to the address below. Completing the enrollment form is easy. Just follow the steps listed below. You can also call the Managed Care Enrollment Center at 1-800-605-3040 for help in completing the form and selecting an MCP. When you select a MCP, you should choose a primary care physician (PCP) for each person in your assistance group or your selected MCP will choose one for you. If you have a PCP already, you can ask your doctor the names of the MCPs he/she is with or you can ask the Enrollment Counselor the MCP your PCP is with.
You may also Enroll online! Enrolling online is a faster alternative to downloading, printing and mailing your form. Just click the button below to get started.
Download Enrollment/Enrollment-Change Form
To download the Enrollment/Enrollment-Change Form, please click the form icon.
Please Note that the form is in PDF format and you will need Adobe Acrobat Reader to view it.
How to fill out your MCP Enrollment/Enrollment-Change Form
These are instructions to help you fill out the Enrollment/Enrollment-Change Form so you and your assistance group can become a member in a MCP.
Step 1 - Case Information
The information in this section is to be completed by the primary information person or assistance group head. The language field should be completed if you need interpreter services.
Step 2 - Enrollment Information
Indicate the new MCP you are selecting for membership. If you are changing MCPs also enter the name of the old MCP and the reason you are changing.
Step 3A - Assistance Group Member(s) Information, Section A
List the name of each member of your assistance group. This information can be found on your Medicaid card or your MCP Member ID Card if you are currently a member of an MCP. In the blocks provided for each assistance group member list his/her relationship to you, their sex, date of birth, Medicaid billing number, and the primary language that person speaks.
For each person listed, write the first and last name of the primary care physician (PCP) you select or the name of the hospital from the MCP's provider directory. You may choose one PCP for the entire assistance group or a different PCP for each member of the assistance group. Remember the PCP(s) you select must be a member of the managed care plan that you selected. You can ask the PCPs, or you can call the Managed Care Enrollment Center at 1-800-605-3040 for help.
Step 3B - Assistance Group Member(s) Information, Section B
List the name of each member of your assistance group who is pregnant, has surgery scheduled, or is receiving ongoing medical treatment including the dates of services or treatment, the doctor's/hospital's name and where he/she is located. Also write the name of each person under the age of 21, using one or more of the codes listed on the back of the enrollment form, if the codes describe the person's health condition. If you have other medical insurance, write down the name of the company and the policy number.
Step 4 - Emergency Contact Information
List the name, relationship, and telephone number of the person the MCP can call in case of an emergency.
Step 5 - Sign and Date the Form
By signing the Enrollment/Enrollment-Change form you agree to the Health Care Enrollment Conditions.
Step 6 - Read About Health Care Enrollment Conditions
It is important that you read the Health Care Enrollment conditions on page two of the enrollment/enrollment-change form.
If you have any questions or need assistance in completing this form, call the Managed Care Enrollment Center at 1-800-605-3040 (or TTY at 1-800-292-3572) and ask to speak with an Enrollment Counselor.
Where to Mail Your Completed Forms