Village Care MAX Member Transfer Request

Member Transfer Request

For member use only. Providers are prohibited from submitting member transfer requests. All transfer requests will be retro-actively effective to the 1st of the current month. Please allow up to 48 hours for transfers to be completed.

Step 1: Search for Provider Office

Search Criteria

Benefit Plan

Zip City

City

Zip

Distance (miles)

Specialist Type

Only Show Offices Accepting New Patients

Advanced Search Criteria (Optional)

Dentist Last Name

Office Name

Office Address

Result Count:

Office #

NPI

License #

Language

Step 2: Select Provider Office to be Assigned

Dentist Name	Office Location	More Info	Select

Step 3: Enter Member Details

OFFICE DETAILS

Office Name:

Office Number:

Provider Number:

Provider Name:

Address:

Phone #:

MEMBER DETAILS

First Name:

Last Name:

Member Medicaid Number:

Member DOB:

Member Contact Information (phone number on file):

I attest that I am a member of Village Care MAX:

Yes

Success Error

By clicking “Submit”, I affirm that I am a member of Village Care MAX. I acknowledge that use of this form by anyone other than the member named above is considered potentially fraudulent and may be subject to corrective action by the Plan.

Please only click Submit once