ARMHS Provider Notification / Change Request

ARMHS Provider

Notification / Change Request
MEMBER INFO
Member Name
UCare ID
PMI
DOB
Address, City, State, Zip
Phone
ICD-10
MEMBER ACKNOWLEDGEMENT
By affixing my signature below, I have decided for my ARMHS services to be delivered by the new ARMHS provider listed above. I was informed of the transfer process and all the information above is accurate to the best of my knowledge. I agree that UCare may use and release information regarding my ARMHS services to the new ARMHS provider above. If member signs with a “X“, signature of Responsible Party (RP) or witness is required.
Member Signature
Signature Date

MonthDayYear
Date
Responsible Member Signature
Signature Date

MonthDayYear
Date
Should be Empty:

ARMHS Provider