How To Complete Your Enrollment Form

Download Enrollment/Enrollment-Change Form

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Please Note that the form is in PDF format and you will need Adobe Acrobat Reader to view it.

How to fill out your MCP Enrollment/Enrollment-Change Form

These are instructions to help you fill out the Enrollment/Enrollment-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 - Enrollment 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 enrollment 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 Enrollment/Enrollment-Change form you agree to the Health Care Enrollment Conditions.

Step 6 - Read About Health Care Enrollment Conditions

It is important that you read the Health Care Enrollment conditions on page two of the enrollment/enrollment-change form. Read and sign your name in the box labeled Consumer Signature, date the form and mail it in with the completed enrollment/enrollment-change form.

Where to Mail Your Completed Forms

Please Mail Your Completed Forms to:
Automated Health Systems
Managed Care Enrollment Center
505 South High Street, Suite 200
Columbus, Ohio 43215