Providers | Resources | Primary Care Physician Change Request

Member Information

First Name^*:

Last Name^*:

Middle Initial:

Member ID#:

Date of Birth^*:

Street Address:

City:

State:

Zip:

Phone Number^*:

Your Email^*:

Select Program:

Current PCP Information

PCP on Member ID (if available):

PCP Tel Nbr (if available):

Have you ever visited your PCP?

Yes
No

New PCP Information

Group Name (if any):

PCP Name:

PCP Street Address:

PCP City:

PCP State:

PCP Zip:

PCP Phone Number:

Reason for Change:

Form completed by:

Phone Number:

Relationship to Member:

Other:

I hereby authorize Affinity Health Plan to make the changes indicated above.

Only one change request per form please. If you have additional requests, please complete separate forms.
Please allow up to 5 business days for us to process this form.

Note: PCP change requests will be retroactive to the 1st of the month that the request was received by Affinity only if the member has active coverage.

Company Name

Primary Care Physician Change Request

Member Information

Current PCP Information

New PCP Information

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