Get Primary Care Physician Change Form - Phoenix Health Plan

Changing your primary care physician can enhance your healthcare experience. This guide will provide you with clear, step-by-step instructions on how to complete the Primary Care Physician Change Form for the Phoenix Health Plan online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. In the section labeled 'New PCP', enter the name of your new primary care physician, including both the last and first name.
3. Provide the provider’s phone number in the designated field to ensure they can be contacted.
4. In the 'Member’s Name' section, input your full name to confirm your identity.
5. Enter the date of service as required. Format this as mm/dd/yyyy.
6. Fill in your Member ID number, which can typically be found on your member card.
7. Input your date of birth in the same format as the date of service.
8. Provide your contact number in the Member Phone field.
9. If applicable, provide the name of the parent or guardian if you are a minor.
10. Sign in the Member Signature field to confirm your request.
11. If you are a minor, the parent or guardian must also sign in the Witness Signature field.
12. Print the names as required in the respective fields to ensure clarity.
13. Enter the date in the appropriate fields and ensure it corresponds to your signatures.
14. Review all the information for accuracy before submitting.
15. Once completed, you have the option to save changes, download, print, or share the form.

Complete your forms online to ensure a smooth transition to your new healthcare provider.