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Molina change provider 2026
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- Click ‘Get Form’ to open the Molina Change Provider form in the editor.
- Begin by entering your name and Molina ID number in the designated fields. Ensure that you print your first and last name clearly.
- Fill in your address, including city, state, and ZIP code. This information is crucial for accurate processing.
- Provide your phone number and an alternate contact number if available. This helps in case there are any questions regarding your request.
- Indicate your current Primary Care Provider's name as listed on your Molina ID card.
- Next, enter the name of the new Primary Care Provider you wish to switch to, along with their address, city, state, ZIP code, and phone number.
- Finally, sign the form as the member or delegated guardian. Print your name and include the date of signing.
- Once completed, fax the form to (630) 203-3993 or mail it to Molina Healthcare of Illinois at the provided address.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2017 | 4.8 Satisfied (145 Votes) |
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change primary care provider form
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