Physician change 2026

1. Click ‘Get Form’ to open the Physician Change Request Form in the editor.
2. Begin by filling in your personal details. Enter your full name, date of birth, Humana member ID number, and phone number clearly in the designated fields.
3. Sign the form where indicated to confirm your consent for the physician change. Ensure you also date your signature.
4. In the 'Current Primary Care Physician' section, provide the name and group/location of your current physician along with their address.
5. Next, fill out the 'New Primary Care Physician' section with their full name, group/location, and address.
6. Specify the effective date of change and provide a reason for this change in the respective fields.
7. If someone else is completing this form on your behalf, they should fill out their name, date, signature, and phone number in the 'Preparer' section.
8. Once all fields are completed accurately, submit the form via fax or mail as instructed at the bottom of the document.

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