Forms

Member Forms

Below are forms that can be used instead of calling Virginia Premier:

Click to Change Your Address
Member Change of Address Form
Member Information
Note: By completing the form below, you are making a temporary change with Virginia Premier Health Plan. Please make a permanent change with the Department of Social Services.

* Indicates required information.
Name*
First Last

Member ID Number*
As it is listed on your Member ID Card.
Date of Birth*
MM
DD
YYYY

Old Address*
Street Address City State ZIP Code

New Address*
Street Address City State ZIP Code

Telephone Number*
(###)###-####
The number we should call if we have questions.
Name of person requesting the change*

Relationship to Member*
Describe Relationship
Name
This field is for validation purposes and should be left unchanged.
Click to Provide Permission to Speak
Permission to Speak Form

Step 1 of 3

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Permisssion to Speak With Form
Member
Please indicate each(all) member(s) whose account you’d like for us to use and/or disclose protected health information.
* Indicates required information.

Name*
First Last

Date of Birth*
MM
DD
YYYY

Member ID*
Address*
Street Address City State ZIP Code

Add another Member?*
No
Yes
Additional Member Information
Name
First Last

Date of Birth
MM
DD
YYYY

Member ID
Address
Street Address City State ZIP Code

Who Can Virginia Premier Speak With?
The person(s) listed below has(have) my permission to transact business on behalf of all of the individuals listed under Member above.
Name*

Phone*
Organization
Relationship to Member(s)*
Address*
Street Address City State ZIP Code

Add Another?*
No
Yes
Name

Phone
Organization
Relationship to Member
Address
Street Address City State ZIP Code

This section is to be completed by Member/Parent/Guardian/Personal Representative
My signature below indicates I have had full opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction to Virginia Premier Health Plan, Inc. I understand that, by signing this form, I am confirming my authorization that Virginia Premier Health Plan, Inc. may use and/or disclose to the persons and/or organizations named on this form the protected health information.

Expiration and Revocation:
Expiration: This authorization will expire on date below.
Expiration Date

Disclaimer: If an expiration date is not indicated above, the authorization period shall be one (1) year from the signature date unless written notification is received from member to revoke at the address listed on the form.
Name*

Electronic Signature: Please type your full name. By typing your name, you are signing this Compliance Attestation electronically. You agree your electronic signature is the legal equivalent of your handwritten signature.
Name of Person Completing This Form*

Relationship to Member(s)*
Describe Relationship

{all_fields}
Click to Request ID Card
Member ID Card Request Form
Member Information:
* Indicates required information.
Member ID Number*
Your Member ID# is the ID# shown on your Member ID Card.
Name*
First Last

Date of Birth*
MM
DD
YYYY

Current Address*
Street Address City State ZIP Code

Where do you want your new card to be mailed?
Is this the address we have on file?*
Yes
No
Is this the address given to the Department of Social Services?
Address given to Social Services
Street Address City State ZIP Code

Note: You must contact the Department of Social Services to update your address.
Phone Number*
The number we should call if we have questions.
Primary Care Physician (PCP)
Email
This field is for validation purposes and should be left unchanged.
Click to Request a PCP Change
PCP Change Request Form
Complete this form to change your Primary Care Physician (PCP).
Complete this form to change your Primary Care Physician (PCP).
Before you fill out this form, please check our provider directory to:

1.) Choose a doctor,
and
2.) Record their address
Member Information
Please note:
This form must be electronically signed by the member / guardian.
* Indicates required information.

Member ID Number*
Name*
First Last

Date of Birth*
MM
DD
YYYY

Address*
Street Address City State ZIP Code

Phone*
PCP Name Currently Listed on Member ID Card
Name of New PCP Requested*
Note: Someone from Member Services will contact you by phone If we have questions about your choice.
PCP Address*
Street Address Address Line 2 City State ZIP Code

Please provide the address for the PCP you selected.
Name of Member or Guardian (Signature)*
Electronic Signature:
Please type your full name. By typing your name, you are signing this Compliance Attestation electronically. You agree your electronic signature is the legal equivalent of your handwritten signature.
Relationship to Member*
Describe Relationship
Note:
The PCP change will become effective on the first day of next month.
Name
This field is for validation purposes and should be left unchanged.

Members

Forms

Member Forms

Member Change of Address Form

Member Information

* Indicates required information.

Permission to Speak Form

Step 1 of 3

Permisssion to Speak With Form

Member

* Indicates required information.

Additional Member Information

Who Can Virginia Premier Speak With?

This section is to be completed by Member/Parent/Guardian/Personal Representative

Member ID Card Request Form

Member Information:

* Indicates required information.

PCP Change Request Form

Complete this form to change your Primary Care Physician (PCP).

Member Information

Please note:

* Indicates required information.

Electronic Signature:

Note: