Forms

Member Forms

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

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)
Name
This field is for validation purposes and should be left unchanged.

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.
Phone
This field is for validation purposes and should be left unchanged.