ATTENTION:
Our main office will be closed Monday, January 18 to commemorate the MLK, Jr. holiday. We will reopen Tuesday, 1/19. All of our CSCs remain closed due to COVID-19; visit
AffinityPlan.org/Live
to speak live with one of our representatives or call us at 866.247.5678.
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Reason for Change:
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Relationship to Member:
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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.