• Need Insurance?
  • Already a Member
  • For Employers
  • For Brokers
  • For Providers
  • Community
Skip Navigation
CareFirst Logo
Log in
  • Home
  • Join Our Networks
    • Professional
      • Credentialing Overview
      • How to Apply
      • Credentialing FAQs
    • Institutional/Ancillary
      • Credentialing Overview
      • How to Apply
      • Credentialing Forms
      • Credentialing FAQs
    • Dental
      • Credentialing Overview
      • How to Apply
      • CAQH Universal Credentialing
      • Credentialing Forms
      • Credentialing FAQs
      • Find a Provider Rep
  • Programs/Services
    • Medical
      • Electronic Capabilities
      • Medical Policy
      • Pre-Cert/Pre-Auth (In-Network)
      • Pre-Cert/Pre-Auth (Out-of-Area)
      • Medical Forms
      • Medical News
      • Payment Policy
    • Dental
      • Dental Overview
      • Dental Electronic Capabilities
      • Dental NPI & Payer Codes
      • Dental Clinical Criteria
      • Dental Forms
      • Dental News
      • Dental Seminar
      • Dental Wellness
    • Pharmacy
      • Pharmacy Exception Requests
      • Pharmacy Resources
      • Pharmacy Prior Authorization
    • Care Management
      • PCMH
      • PCMH News
      • Quality & Affordability
      • Clinical Resources
      • Profile Score
      • Virtual Connect Program
    • Wellness/Incentives
      • Blue Rewards
  • Resources
    • Administrative
      • CareFirst Direct
      • Update Practice Info
      • Manuals & Guides
      • Forms
      • Inquiries & Appeals
      • Medicare Appeals and Grievances
    • Claims
      • Claims Submission
      • Dental Claims Submission
      • NPI
      • Dental NPI & Payer Codes
      • Ancillary Claims
      • Corrected Claims
      • Medicare Secondary
      • Paper Claims
    • Resources
      • Looking for Support?
      • Federal Employee Program
      • CareFirst Direct User Guides
    • News/Training
      • Learning and Engagement Center
      • Newsletters
      • News Archives
  • Manuals and Guides
  • Print
    A
    A
    A

Care Management

  • PCMH
    • Overview
    • Enrollment Materials
    • Forms
    • PCMH Program FAQs
    • Evaluation
  • PCMH News
  • Quality & Affordability
    • After Hours Care
    • National Laboratories
    • Radiology Centers
    • Ambulatory Surgery Centers
    • Medication Choices
    • Profile Score
  • Clinical Resources
    • Clinical Practice Guidelines
    • Preventive Service Guidelines
    • Disease Management
    • High-Risk Pregnancy Program
    • Opioid Support
  • Profile Score
  • Virtual Connect Program
providers

PCMH Forms

PCMH Enrollment

Attachment A
Attachment B
Program Checklist
PCMH Change in Provider Information
Medical Panel Transfer Form

PCMH Member

Enhanced Monitoring Member Service Request Form - No Care Plan Required
Enhanced Monitoring Member Consent Form - No Care Plan Required
Election to Participate Form
Election to Participate Form - Large Print
Election to Participate Form

- Spanish version
Election to Participate Form

- Korean version
Revocation of Election to Participate
Revocation of Election to Participate

- Spanish version
Revocation of Election to Participate

- Korean version
See More
  • About Us

    • Coronavirus Resource Center
    • Transformation
    • We Stand Against Injustice
    • Company Overview
    • Our History
    • Awards & Recognition
    • Corporate Offices & Locations
    • Service Area
    • Media Releases
  • Legal & Mandates

    • Patient Rights & Responsibilities
    • Member's Privacy Policy
    • HIPAA
    • Health Care Fraud Prevention
    • Quality Improvement
    • Mental Health Parity
    • Developer Portal
    • Machine Readable Data
    • Machine Readable File Mandate
    • Surprise Billing - Out-Of-Network Provider Notice
  • Other Information

    • Community
    • Health Insurance Glossary
    • Looking for Support?
    • Send Us Your Feedback
Facebook Twitter YouTube LinkedIn Instagram

Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc.

In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are is the business names of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only.