Humana

Humana
Primary Care Physician Change Request Form

(To be completed and submitted by the physician with the patient's consent) (Please print clearly and complete ALL fields

Your primary care physician is the doctor you go to first and most often for your health care needs and for guidance about important preventive care to keep you healthy and active. By signing this form, you are selecting a new primary care physician and notifying Humana to make this change to its files.

Option for member to self-select primary care physician by phone You also can select a different doctor as your primary care physician by calling Humana at the number found on the back of your ID card.

Option for member to select primary care physician in physician's office
Patient name
Date of birth

MonthDayYear
Date
Humana member ID
Phone number
Patient signature

Clear
Date

MonthDayYear
Date
Current primary care physician
Name
Group/location
New Primary Care Physician
Full name
SC House Calls or Other
Group/location
Tax ID
SC House Calls ID: 20-5227543
Address
Effective date of change

MonthDayYear
Date
Vendor/center number (if known)
Reason for change
Current Primary Care Provider
Preparer name
Date

MonthDayYear
Date
Preparer signature

Clear
Phone number
Please submit the completed form to Humana by fax at 1-800-633-8188 or by mail to Humana, P.O. Box 14168, Lexington, KY 40512-4168.

NOTE: All change requests are subject to verification and physician availability.
Should be Empty:

New Primary Care Physician