Molina change provider 2026

1. Click ‘Get Form’ to open the Molina Change Provider form in the editor.
2. Begin by entering your name and Molina ID number in the designated fields. Ensure that you print your first and last name clearly.
3. Fill in your address, including city, state, and ZIP code. This information is crucial for accurate processing.
4. Provide your phone number and an alternate contact number if available. This helps in case there are any questions regarding your request.
5. Indicate your current Primary Care Provider's name as listed on your Molina ID card.
6. 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.
7. Finally, sign the form as the member or delegated guardian. Print your name and include the date of signing.
8. 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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