(PCP) Change Form - Coordinated Care Health 2026

1. Click ‘Get Form’ to open the (PCP) Change Form in the 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 your change request. This should align with your plan’s selection/change policy.
5. Indicate your reason for changing from your assigned PCP by selecting all applicable options from the list provided.
6. Sign and date the form at the bottom as either a member or authorized representative.
7. Once completed, save your changes and follow instructions to fax or mail the form to Coordinated Care Member Services.

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