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It explains multiple enrollment options, including using ncmedicaidplans.gov, the NC Medicaid Managed Care mobile app, phone support, or mailing/faxing the completed form. 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Or enroll online, using the mobile app, or by phone.  \nPATRICIA A. JONES 1234 ANY MAIN STREET RALEIGH, NC 27603-1000  \nSAMPLE  \nChoose or change your health plan in one of these ways:  \n1. Go to [ncmedicaidplans.gov](ncmedicaidplans.gov).  \n2. Use the free NC Medicaid Managed Care mobile app.  \n3. Call us at 1-833-870-5500 (TTY: 1-833-870-5588) .  \n4. Fill out this form and mail it to us in the envelope provided. Or fax it to 1-833-898-9655.  \nMEDICA ID EB ENROLL FORM | 6 PERSON | ENG 190826  \n\n| Person 1 PATRICIA A. JONES, 02/16/1985 | ID Number: XXX-XX-XXXX |\n| --- | --- |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| Do you want this PCP for everyone listed on this form? ■ Yes ■ No |  |\n| ⊲ Choose one health plan.\u003Cbr>􀂅 WellCare 􀂅 HealthyBlue\u003Cbr>􀂅 UnitedHealthcare Community Plan 􀂅 AmeriHealth Caritas |  |\n| Person 2 | ID Number: |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| ⊲ Choose one health plan. |  |\n| Person 3 | ID Number: |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| ⊲ Choose one health plan. |  |\n\nQuestions? Go to [ncmedicaidplans.gov](ncmedicaidplans.gov. Or)[. Or](ncmedicaidplans.gov. Or) call us at 1-833-870-5500 (TTY: 1-833-870-5588). The call is free. We can speak with you in other languages.  \nTo get this information in other languages or formats such as large print or audio, call 1-833-870-5500.  \nMEDICA ID EB ENROLL FORM | 6 PERSON | ENG 190826  \n\n| \u003Cbr>Person 4 | ID Number: |\n| --- | --- |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| ⊲ Choose one health plan. |  |\n| Person 5 | ID Number: |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| ⊲ Choose one health plan. |  |\n| Person 6 | ID Number: |\n| ⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health plan you choose. |  |\n| PCP’s first and last name | PCP’s phone number (optional)( ) |\n| PCP’s address (street, city, state, ZIP Code) |  |\n| ⊲ Choose one health plan. |  |\n\nIf a Medicaid member is not listed on this Enrollment Form:  \n■ Call us at 1-833-870-5500 (TTY: 1-833-870-5588), or  \n■ Write the member’s name and ID number in a blank space on this form. Then choose the member’s primary care provider (PCP) and health plan.  \n\n| Sign and date |  |  |\n| --- | --- | --- |\n| ⊲ Head of household or guardian sign here Date |  |  |\n| ⊲ Authorized representative If you are an authorized representative for this household, fill out this section and sign below. |  |  |\n| Name of authorized representative | Phone number\u003Cbr>( ) |  |\n| Address (street, city, state, ZIP Code) |  |  |\n| ⊲ Authorized representative sign here |  | Date |","cbCaiu9ZzwROkKIp","https://ap.wps.com/l/cbCaiu9ZzwROkKIp","pdf",157658,"English","# Choose or change a health plan and PCP\n## Ways to enroll\n## Select PCP and health plan for each person\n## Add missing Medicaid members\n## Sign and date","[{\"question\":\"How can I choose or change a health plan and PCP?\",\"answer\":\"Use ncmedicaidplans.gov, the NC Medicaid Managed Care mobile app, call the phone number listed, or fill out the form and mail or fax it using the provided contact details.\"},{\"question\":\"What information must be completed for each person on the form?\",\"answer\":\"For each listed person, choose a primary care provider (PCP) and select one health plan. The form also requires the person’s ID number and PCP contact/address details.\"},{\"question\":\"What should I do if a Medicaid member is not listed on the Enrollment Form?\",\"answer\":\"Call the listed number or write the member’s name and ID number into a blank space on the form, then choose that member’s PCP and health plan.\"},{\"question\":\"Who needs to sign and date the form?\",\"answer\":\"The head of household or guardian signs and dates. If there is an authorized representative, that person completes their section and signs below with the date.\"}]","Enrollment Form - Choose or Change a Health Plan and PCP | PDF",1789831100]