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. A provider’s office can also request a PCP change on behalf of a Neighborhood member by completing this PCP Change electronic form (eForm). The PCP Change eForm must be completed by the provider (or office representative) who the member has requested be their new PCP. • 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 submitted. • 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. After you submit this form, you will receive an email confirming submission of your PCP change request. You will not receive notification that your request was processed, but all changes can be verified on NaviNet after one (1) business day. New Provider InformationNPI Number(Required)Entering the NPI Number will automatically populate the Provider Name and Address Location(s) fields below. HiddenProviderType HiddenProviderHCCID Provider Name(Required) Error Message Address Location(Required)Please select an address from the dropdownHiddenAddress HiddenProviderLocationHCCID Contact Email Address(Required) Member Information - Member 1Neighborhood Member ID#(Required) Member DOB(Required) MM/DD/YYYYMember DOS(Required) MM/DD/YYYYMember Name Member's Plan Name Active During Date of Service Member Information - Member 2Neighborhood Member ID# Member DOB MM/DD/YYYYMember DOS MM/DD/YYYYMember Name Member's Plan Name Active During Date of Service Member Information - Member 3Neighborhood Member ID# Member DOB MM/DD/YYYYMember DOS MM/DD/YYYYMember Name Member's Plan Name Active During Date of Service 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. Authorized Signature(Required)Date(Required) MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.