Forms

Listen

As a member, you can use the forms below to do things like get a new ID card, or change your Primary Care Provider (PCP). You can also call Member Services for help.

Change Your Address

Use this form to let Virginia Premier know when you’ve got a new address.

Member Change of Address Form (pdf)

Give Virginia Premier Permission to Speak

Use this form if you would like to give Virginia Premier permission to speak with someone else (e.g., a family member) about your health information.

Permission to Speak With Form (pdf)

Request ID Card

Use this form if you would need a new ID card.

Member ID Request Form (pdf)

Member ID Card Request Form

Member Information:
* Indicates required information.
Name*
First Last
Member ID Number*
Your Member ID# is the ID# shown on your Member ID Card.
Date of Birth*

YYYY
MM
DD
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)
Phone
This field is for validation purposes and should be left unchanged.

Request a PCP Change

Complete this form to change your Primary Care Physician (PCP). Use our provider directory to choose a doctor and find their address.

PCP Change Request Form (pdf)

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.
Name*
First Last
Member ID Number*
Date of Birth*

YYYY
MM
DD
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.

Substance Use Disorder Member Release of Confidential Information Consent Form

Use this form if you would like to give Virginia Premier permission to disclose information to someone else (e.g., a family member or doctor) about your treatment for substance use disorder.

Substance Use Disorder Member Release of Confidential Information Consent Form (pdf)

Change Your Address

Give Virginia Premier Permission to Speak

Request ID Card

Member ID Card Request Form

Member Information:

* Indicates required information.

Request a PCP Change

PCP Change Request Form

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

Member Information

Please note:

* Indicates required information.

Electronic Signature:

Note:

Substance Use Disorder Member Release of Confidential Information Consent Form

Questions? Please contact us here.

User ID:

Password: