Member change form

Please complete the information related to your changes and "submit" this form. With this form you can:

  • Request an ID card
  • Change your PCP

Changes regarding: Medical coverage
Dental coverage
Medical and dental coverage

  Format: 00-00-0000
   

For authentication purposes, at least one field below is required*:

  Format: 111-111-1111

Request ID card?

   

Change PCP?

   
Steps to selecting a new PCP:
  1. View our directories to choose a new PCP on your plan's network.
  2. Contact your new PCP's office to ask if they will accept you as a patient; some offices do not accept new patients.
  3. Remember your new PCP is effective at the beginning of the next month.
  4. You may change your PCP up to two times every six months.

Established patient?

Comments:

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Disclaimer
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