Request change care provider form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and Molina ID number in the designated fields. Ensure you print both your first and last name clearly.
3. If applicable, list additional family members by filling in their names and Molina ID numbers as well.
4. Provide your complete address, including city, state, and ZIP code. Make sure all information is printed clearly.
5. Indicate your current Primary Care Provider's name as listed on your Molina ID card.
6. Next, specify the new Primary Care Provider you wish to change to, along with their address and phone number.
7. Sign the form where indicated, providing your relationship if you are a delegated guardian. Print your name and date below the signature line.
8. Once completed, fax the form to (614) 781-1474 or mail it to the provided address for processing.

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