Change Your Primary Care Physician (PCP)

Your relationship with your Primary Care Physician (PCP) is very important. You may change your PCP at any time by submitting the form below or by calling Customer Service at the number listed on the back of your member ID card. Please note that you must continue to see your current PCP until your request to change has been processed. You will receive a new ID card, which lists your new PCP and the effective date of the change.

*Member Number (on ID Card)  
Group Number
*Member First Name  
*Member Last Name  
Middle Initial
*Member Address  
*Email Address    
(if Other)
If Changing Due to a Quality of Care issue, please select an option from the drop down menu as the reason you are changing

New Primary Care Physician

*Physician's Name  
PCP Code  
*Requested Effective Date of Change    
Phone Number