Primary care provider change request form Your primary care provider (PCP) is the main person you see for health care. If you want to ask for a new PCP who works with your plan, fill out this form and fax it to 1-866-840-4993. Please allow 24 to 72 hours for processing. Member/patient information:
Signature of member or responsible party:
Please fax this form to 1-866-840-4993.
To make a request by phone, please call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday from 7 a.m. to 7 p.m. Eastern time.