PCP Change

  • All Neighborhood Health Plan of Rhode Island (Neighborhood) members are assigned a primary care provider (PCP) displayed on the member’s Neighborhood identification card. A member may change the PCP assigned to them at any time by calling Neighborhood Member Services at the number listed on their ID card.

    The Provider’s office can also request a PCP change on behalf of the Neighborhood member by completing this form. The PCP Change Form must be completed by the provider (or office representative) who the member requested be their new PCP and return it to Neighborhood Member Services via fax number (401) 709-7093.

    • The PCP Change Form must be received by Neighborhood within five (5) business days from the date of service listed below for services to be considered for payment (the date of service will be the effective date). Forms received after five (5) business days will be effective on the date the information was faxed.
    • PCP changes for newborns will be accepted up to thirty (30) days from date of birth (DOB).

    In order to ensure timely and accurate processing of the PCP change, please complete all fields on this form. Providers will not receive confirmation from Neighborhood that the form was received or processed. All changes can be verified on NaviNet after five (5) business days.

  • New Provider Information

  • Member Information

  • Neighborhood Member ID #Member DOB (mm/dd/yyyy)Date of Service (mm/dd/yyyy)Member NameMember's Plan NameActive 
    Add a new row
    Member information will populate after entering Member ID# and DOB
  • By Signing below I hereby attest that the information on this form requested by the member/authorized representative is true, accurate and complete to the best of my knowledge.

  • MM slash DD slash YYYY