(PCP) Change Form - Coordinated Care Health 2025

1. Click ‘Get Form’ to open the (PCP) Change Form in our editor.
2. Begin by filling out the Member Information section. Enter your last name, member ID, date of birth, SSN, telephone number, and mailing address. Ensure all required fields are completed.
3. In the PCP Change Request section, provide the requested PCP's name and NPI number. Fill in their office address, city, and phone number.
4. Select the effective date for the change and indicate your reason for changing PCP by checking all applicable boxes. This helps streamline your request.
5. Sign and date the form at the bottom as either a member or authorized representative. Make sure to print your name clearly.
6. Once completed, you can easily download or share the form directly from our platform for submission via fax or mail as instructed.

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