Updated NC Medicaid Standard Plan PCP Change Forms
The Standard Plans (SP) have updated their PCP Change Forms. These forms may be submitted when a member requests to change their Primary Care Provider (PCP), thereby adding the member to the provider’s panel.
In response to provider feedback, the forms have been revised to allow PCPs to attest to verbal member consent in cases where a written signature cannot be obtained.
Below are the links to each SP’s updated form:
- AmeriHealth Caritas NC https://www.
amerihealthcaritasnc.com/ assets/pdf/provider/request- for-change-of-pcp.pdf - Carolina Complete Health https://network.
carolinacompletehealth.com/ content/dam/centene/ carolinacompletehealth/pdfs/ CCH-PCP-Change-Form-2025.pdf - Healthy Blue NC https://provider.
healthybluenc.com/docs/gpp/ HBNC_CAID_ ChangeRequestFormInst.pdf?v= 202505021752 - United Healthcare https://www.uhcprovider.com/
content/dam/provider/docs/ public/commplan/nc/forms/NC- UHCCP-PCP-Change-Fax-Form.pdf - WellCare https://www.wellcarenc.com/
content/dam/centene/wellcare/ nc/pdfs/NC_Caid_Prov_PCP_ Change_Request_Form_04_2025_R. pdf