Enrollment And Disenrollment Form printable pdf download

Enrollment And Disenrollment Form

ENROLLMENT and DISENROLLMENT FORM

(Complete top sections for enrollments and bottom section for disenrollments.)

Enrollments

1. To Change Plans

Coventry Health Care of Kansas, Inc.

_______ Unicare

_________

_______ HealthConnect (SSI/GA/MKN) (Region 3) (Complete next section also if HCK.)

2. To Change Primary Providers for Beneficiaries in HealthConnect

Primary Provider Name _____________________________________________________

Provider Medicaid Number _______________Provider Phone Number _______________

Beneficiary Name

Medicaid ID Number

Beneficiary Telephone

Print beneficiary/casehead name_________________________________________________________________

Beneficiary/casehead signature (Required on enrollments)_____________________________Date___________

Provider signature_____________________________________________________________Date___________

Disenrollment

3. To Dismiss a Beneficiary

Provider Name ____________________________________________________________

Provider Medicaid Number _______________Provider Phone Number ________________

Beneficiary Name

Medicaid ID Number

Beneficiary Telephone

Reason for disenrollment:

______Beneficiary is abusive to provider & staff.

______ Beneficiary previously removed from PCCM.

______Beneficiary fails to follow medical advice.

______ Beneficiary fails to keep appointments.

______Beneficiary fraud.

(List dates below.)

Explanation:____________________________________________________________________________________

_______________________________________________________________________________________________

Provider Signature___________________________________________________________Date________________

FAX COMPLETED FORM TO 785-266-6109

Revised 01/2012

Enrollment And Disenrollment Form