April 2021

The Member Site Change Request Form authorizes Neighborhood to process PCP Site Changes at a Neighborhood member’s request.

• This form was recently updated to remove the Provider ID requirement, and now requests a provider NPI instead.

Providers have five (5) business days from the date of service to fax this request to Neighborhood; otherwise site changes will be effective on the date the information was faxed. This form must be signed by the member or member’s parent/head of household in order to be processed. If the member prefers to speak with a Member Services Specialist, please have them contact Neighborhood Member Service at 800-963-1001.