GCM_Provider Change Request

Patient Full Name

First NameLast Name

Date of Birth

Contact Email Address

example@example.com

Contact Phone Number

Please enter your best contact number.Format: (000) 000-0000.

Current Provider Name

Select the provider you are currently seeing. This helps us verify your records and ensure continuity of care.

Other (please specify)

Requested New Provider Name

Select the provider you would like to continue care with. If your provider is not listed, choose ‘Other’ and specify below.

Other (please specify)

Reason for Provider Change

Other (please specify)

Important Acknowledgements

I confirm that this request is being made voluntarily and without influence or persuasion from staff or providers.

If you feel your decision was influenced or if you would like to share additional context, please let us know below. A team member will follow up with you as needed.

Please share any details you feel are important.

Additional comments or context about your request (optional):

Patient Signature (authorize this request)

Date of Submission

Date

Important Information & Acknowledgements

Our practice supports patient choice while ensuring continuity and quality of care. Provider changes are handled using a standardized process to ensure appropriate clinical review and coordination. All providers and staff remain neutral and do not influence patient decisions. Submission of this form does not guarantee immediate scheduling. All provider change requests are reviewed to ensure appropriate care continuity and may require additional coordination before an appointment is scheduled. By submitting this request, I understand that my medical records will remain within the practice and be accessible to my care team as needed to support safe and continuous care. If you have questions about this form or the provider change process, a team member will be happy to assist you.

Provider Change Request Form

Office Use Only

OFFICE USE ONLY: