Update Member Assignment Limitations

What would you like to do? *

If you use your social security number as your tax ID number, do not fill out this form. Please contact your provider representative to update your accepting new members status.

Practitioner Name

Service Location Address

Practitioner Type *
Is Practitioner Accepting New Members? *
Programs to Update (Choose all that apply) required *

Update Requested By

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Primary Care Provider (PCP) Name

Service Location Address

Update Requested By

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Practitioner Name

Service Location Address

Practitioner Type *

Update Requested By

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.