Empanelment Resource 7:

Example PCP Change Form

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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.

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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

Phmi Pcpchangeprocess

 

Endnotes

  1. Coordinated Care. PCP Selection and Change Form; [cited 2023 July 13]. Available from: https://www.dochub.com/fillable-form/ 105553-pcp-change-form-coordinated-care-health.