Member Primary Care Provider Change Request
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Members have the right to choose a primary care provider in the Plan’s network. If a member wants to change their primary care provider, help them fill out the Member Primary Care Provider Change Request Form (PDF). After the form is filled out, providers are responsible for submitting the completed form using the fax number on the form to process the change.
Ensure the member prints clearly and completes all required fields on the form. The member must also sign the bottom of the form before you submit it.