PCP Change Form - Univera Healthcare 2026

1. Click ‘Get Form’ to open the PCP Change Form in the editor.
2. Begin by entering today’s date at the top of the form. This helps track when the request is made.
3. Fill in your Member ID# and your name clearly in the designated fields. If applicable, include your parent or guardian's name as well.
4. Indicate the reason for changing your Primary Care Provider (PCP) in the provided section. Be concise but clear.
5. Sign the form where indicated, ensuring that either you or your parent/guardian provides a signature if necessary.
6. Enter the name of your new Medical PCP and OB/GYN in their respective fields.
7. Specify the effective date of change, which should be set for the first day of the upcoming month.
8. Once completed, fax the form to Customer Service using one of the provided numbers based on your plan type.

Start using our platform today to easily complete and submit your PCP Change Form for free!