• Primary Care Physician Change Request

  • Member Information


    Current PCP Information


    New PCP Information


    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.