Empanelment Resource 7:
Example PCP Change Form
©️ 2024 Kaiser Foundation Health Plan, Inc.
This resource is part of the Empanelment Implementation Guide, offering steps and activities to help your practice select and implement a methodology to create patient panels and develop continuity reports. It is the second in the “Building the Foundation” series of implementation guides.
PCP Change Form
Use this template to develop your own form for patient-initiated PCP changes.[1]
PCP Change Request Form |
||||||
To change your primary care provider (PCP) at [Health Center Name] to another primary care provider, please complete this form. |
||||||
Patient Information |
||||||
Patient ID: |
Patient Name: |
|||||
Request Initiated By (Patient or Provider): |
||||||
Signature of Patient, Parent or Guardian: |
||||||
Date: |
||||||
PCP Change Information |
||||||
Current PCP |
||||||
Current Assigned Clinic |
||||||
Requested Effective Date of Change: |
||||||
Staff Member Conducting PCP Change: |
||||||
Reason for Change (select all that apply): |
PCP Gender |
PCP Hours Did Not Fit Patient Need |
Language Communication Barriers |
|||
PCP Location |
Provider Change Requested |
Wait Time in Provider Office |
||||
Quality of Care |
Other |
|||||
New PCP Information |
||||||
New PCP: |
||||||
New Assigned Clinic: |
||||||
PCP Change Process
