Follow the steps to complete the Molina PCP Change Form online

1. Press the ‘Get Form’ button to access the form and view it in the editor.
2. Begin by entering the member’s name in the designated field. Ensure you print your first and last name clearly.
3. Input the member’s Molina ID number and date of birth. These details are crucial for identifying your record.
4. If you are changing the provider for additional family Molina members, repeat the process for their names and ID numbers in the additional family members section.
5. Fill out the member’s address, including the city, state, and ZIP code.
6. Provide your phone number and alternate contact number if applicable.
7. Indicate your current primary care provider’s name as listed on your Molina ID card.
8. Specify the name of the new primary care provider you wish to change to.
9. Fill in the new provider’s address, along with the city, state, and ZIP code.
10. Enter the new provider's phone number for any further communication.
11. Provide your signature or that of a delegated guardian. Include the relationship of the guardian if applicable.
12. Print your first and last name under the signature line along with the date.
13. Once all fields are completed, choose to save your changes, download, print, or share the form as needed.

Complete your Molina PCP Change Form online today for a smooth transition!