Provider Change Request Form

Provider Change Request Form

Complete this form to change your Foundational Community Supports (FCS) provider. Please allow Wellpoint up to 5 business days to complete your request. In instances where a new provider is not assigned, additional processing time may be necessary due to limited providers with capacity.

For questions, please call FCS at 844-451-2828 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Pacific Time or email at FCSTPA@wellpoint.com.

Enrollee Information

Service Type*

Select

First Name*

Last Name*

ProviderOne Number*

Ex: 123456789WA

Date of Birth*

Phone Number

Phone

Address

City*

State*

Zip Code*

County

Select

Current Provider Information

Current Provider Agency Name*

Select

Provider Contact Name

Provider Email Address

Provider's Phone Number

Phone

Provider's City, State, Zip Code

Number of units used

Dollar amount of TAP fund used

Only applicable for Housing

New Provider Information

New Provider Agency Name*

Select

Provider Contact Name

First Name and Last Name

Provider Contact Email Address

Phone Number

Phone

Street Address

City, State, Zip Code

Reason for Request*

Select all that apply and/or type reason for request

Select or enter value

PCR Enrollee Signature*

The new PCR Consent Form needs to be signed and dated by the enrollee and uploaded in this Smartsheet form. This document is required for all Provider Change Requests to be processed.

Drag and drop files here or

Enrollee Signature*

I, the enrollee, understand that it is my choice to change my FCS provider and I’m not required to work with a specific provider because that is where they have housing. By entering my first and last name, I give consent to share my information with other health and social care professionals for the purpose of obtaining supportive housing and/or supported employment services.

Signature Date

Time Consent Received*

Send me a copy of my responses

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