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 Selection Services 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.

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.

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 3. 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 Selection Services Center at 1-800-605-3040 for help.

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. Authorization to Treat Minors: In an emergency your MCP may not be able to reach you or the person you listed as an emergency contact. Read and sign here so that your child can receive medical treatment in the case of emergency.

Step 6. 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 Selection Services Center at 1-800-605-3040 (or TTY at 1-800-292-3572) and ask to speak with a Selection Counselor.

Please mail completed forms to...

Automated Health Systems
Selection Services Center
505 South High Street, Suite 100
Columbus, Ohio 43215

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