To join an MCP or to change your current MCP
you need only to complete the Selection/Selection-Change form
and mail it to the address below. Completing the Selection/Selection-Change
Form is easy. Just follow the steps listed below. You can
also call the Managed Care Enrollment Center at 1-800-605-3040 for
help in completing the form and selecting an MCP. When you select
a MCP, you should choose a primary care physician (PCP) for each
person in your assistance group or your selected MCP will choose
one for you. If you have a PCP already, you can ask your doctor
the names of the MCPs he/she is with or you can ask the Selection
Counselor the MCP your PCP is with.
NEW ! You may now
Enroll on-line ! A faster Alternative to download, print and
mail your form !
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![]() HOW
TO FILL OUT YOUR MCP SELECTION/SELECTION-CHANGE FORM |
These are instructions to help you fill out the Selection/Selection Change Form so you and your assistance group can become a member in a MCP
![]() DOWNLOAD
SELECTION FORM |
![]() STEP
1- CASE INFORMATION |
 The information in this section is to be completed by the primary information person or assistance group head. The language field should be completed if you need interpreter services.
![]() STEP
2 - SELECTION INFORMATION |
Indicate the new MCP you are selecting for membership. If you are changing MCPs also enter the name of the old MCP and the reason you are changing
![]() STEP
3A - ASSISTANCE GROUP MEMBER(S) INFORMATION, SECTION A |
List the name of each member of your assistance group. This information can be found on your Medicaid card or your MCP Member ID Card if you are currently a member of an MCP. In the blocks provided for each assistance group member list his/her relationship to you, their sex, date of birth, Medicaid billing number, and the primary language that person speaks.
For each person listed, write the first and last name of the primary care physician (PCP) you select or the name of the hospital from the MCP's provider directory. You may choose one PCP for the entire assistance group or a different PCP for each member of the assistance group. Remember the PCP(s) you select must be a member of the managed care plan that you selected. You can ask the PCPs, or you can call the Managed Care Enrollment Center at 1-800-605-3040 for help.
![]() STEP 3B - ASSISTANCE GROUP MEMBER(S) INFORMATION, SECTION B |
List the name of each member of your assistance group who is pregnant, has surgery scheduled, or is receiving ongoing medical treatment including the dates of services or treatment, the doctor's/hospital's name and where he/she is located. Also write the name of each person under the age of 21, using one or more of the codes listed on the back of the selection form, if the codes describe the person's health condition. If you have other medical insurance, write down the name of the company and the policy number.
![]() STEP 4 - EMERGENCY CONTACT INFORMATION |
List the name, relationship, and telephone number of the person the MCP can call in case of an emergency.
![]() STEP 5 - SIGN AND DATE THE FORM |
By signing the Selection/Selection Change form you agree to the Health Care Selection Conditions.
![]() STEP 6. READ ABOUT HEALTH CARE SELECTION CONDITIONS |
It is important that you read the Health Care Selection conditions on page two of the selection/selection change form. Read and sign your name in the box labeled Consumer Signature, date the form and mail it in with the completed selection/selection change form
If you have any questions or need assistance in completing this form, call the Managed Care Enrollment Center at 1-800-605-3040 (or TTY at 1-800-292-3572) and ask to speak with an Enrollment Counselor. |
![]() WHERE TO MAIL YOUR COMPLETED FORMS... |
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Please
Mail COMPLETED Forms to :
Automated
Health Systems
Managed Care Enrollment Center
505 South High Street, Suite 200
Columbus, Ohio 43215 |
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