PCP Change Request

Online PCP Change Request Form

To request a new primary care provider (PCP), complete this Primary Care Provider Change Request form. If you have any questions or need assistance, please contact our Customer Service department at 1-714-246-8500 or toll-free at 1-888-587-8088, Monday through Friday, from 8 a.m. to 5:30 p.m. We have staff who speak your language. TDD/TTY users can call 1-800-735-2929.

*=Required field


 

PCP Information

Provider ID: Provider ID
Provider Name: Provider Name
Networks: Networks
Provider City: City

Member Information

 
 
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/ /  
Check this box if you do not have a current address
 
 
 
 

Requestor Information

 

 
 
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Network Information

 
 
 

Warning: Any current or pending prior authorization(s) with your current health network will no longer be valid if you change to a different Health Network.

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